LIBRARY 

OF  THE 

UNIVERSITY  OF  CALIFORNIA. 

GIFT    OF 

\. 

Class  * 


V 


A  TREATISE 


ON 


MEDICAL  EXAMINATION 


FOR 


LIFE  INSURANCE. 


BY 


J.  E.  LEVAN,   M.D., 

MEDICAL  DIRECTOR  OF  THE  FIDELITY  MUTUAL  LIFE  ASSOCIATION. 


PHILADELPHIA : 

PRESS   OF  WM.   F.   FELL  &   CO., 

No.  1220-24  SANSOM  STREET. 

1885 


Entered,  according  to  Act  of  Congress,  in  the  year  1885,  by 

J.  R.  LEVAN,  M.D., 
In  the  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


PREFACE. 


A  strong  sense  of  the  need  of  a  treatise  describing, 
more  fully  than  any  the  author  has  so  far  been  able  to 
find,  a  theoretical  and  practical  system  of  examination 
for  the  insurance  of  lives,  could  alone  move  him  to 
prepare  and  offer  to  the  insurance  public  the  present 
work. 

Having,  however,  carefully  studied  and  investigated 
the  array  of  facts,  that  practical  experience  and  close 
observation  in  this  field  have  from  time  to  time  brought 
to  light,  he  became  convinced  that  it  would  be  neither 
unwarranted  nor  presumptuous  to  prepare  a  convenient 
and  comprehensive  manual  that  should,  in  some  degree, 
meet  the  wants  of  the  medical  examiner. 

With  this  explanation  of  the  reason  prompting  its 
preparation,  the  author  submits  his  work  to  the  candid 
examination  of  the  medical  fraternity  and  insurance 
officers,  sincerely  hoping  that  it  may  be  of  some  use 
in  supplying  the  demands  mad6  by  the  recent  gigantic 
growth  of  the  life  insurance  interest. 

In  conclusion,  he  would  state  that  it  affords  him  great 
pleasure  to  acknowledge  his  obligation  to  Dr.  Horace 
G.  Hill,  for  advice  and  assistance  in  the  completion  of 
this  Treatise. 

NOTE. — For  the  chart  of  heart  murmurs,  on  page  41,  I  am  indebted 
to  Dr.  Judson  Daland. 


733  North  41st  street. 


Ill 


218845 


CONTENTS. 


PART  I. 


THE  EXTERNAL  MAN. 


PAGE 

9 


PART  II. 
THE  CIRCULATORY  SYSTEM 31 

PART  III. 
THE  RESPIRATORY  SYSTEM 53 

PART  IV. 

THE  DIGESTIVE  SYSTEM 75 


PART  V. 
THE  URINE,  AND  GENSTO- URINARY  ORGANS.. 


95 


PART  VI. 
DISEASES  OF  THE  BLOOD  AND  BLOOD-MAKING  ORGANS 135 

PART  VII. 
DISEASES  OF  THE  NERVOUS  SYSTEM.. 143 

PART  VIII. 
HEREDITARY  TRANSMISSION 151 

PART  IX. 

THE  PERFECT  AND  THE  IMPERFECT  MAN .  161 


APPENDIX  , 


PART  X. 

v 


175 


PART  I. 

THE  EXTERNAL  MAN. 


PART  I. 

THE  EXTERNAL  MAN. 


Under  this  caption  are  submitted,  for  convenient 
reference,  whatever  signs,  symptoms,  or  phases  of  de- 
velopment, favorable  or  unfavorable,  may  be  percep- 
tible in  the  person  of  the  applicant,  to  the  eye,  ear,  or 
touch  of  the  examiner. 

THE  APPLICANT. 

In  every  case  where  the  applicant  for  insurance  is 
not  personally  known,  a  careful  investigation  is  im- 
peratively necessary.  The  medical  inquirer  must  be- 
come fully  assured  that  the  individual  before  him  is  in 
fact  the  person  named  in  the  form  of  application.  False 
presentation  of  applicants  has  been  and  may  be  at- 
tempted by  shrewd  and  cunning  knaves,  and  the  insur- 
ance company  subjected  to  fraudulent  losses,  through 
carelessness  or  easy  confidence  on  the  part  of  the  ex- 
aminer. 

AGE. 

As  regards  age,  in  relation   to   life  insurance,  the 
opinions  are  many  and  varied.     To  rehearse  them  is 
not  now  necessary,  and  we  have  neither  time  nor  space 
2  9 


10  TREATISE   ON    MEDICAL   EXAMINATION. 

to  discuss  them  here.  There  are  some  facts,  however, 
on  the  subject,  which  bear  scrutiny,  and  should  be  duly 
considered  by  all  intelligent  practitioners,  and  to  these 
we  invite  special  attention. 

It  is  recognized  that  young  persons,  from  the  tenth 
to  the  .eighteenth  year,  are  more  generally  liable  to  in- 
flammatory affections  than  those  of  more  mature  age. 
Among  inflammatory  diseases  we  particularly  class 
pneumonia,  pleurisy,  carditis,  acute  consumption, 
rheumatism,  and  kindred  diseases.  These  are  usually 
more  serious  in  young  subjects,  and  frequently  prove 
fatal. 

From  eighteen  to  forty  is  admitted  to  be  the  most 
healthful  period.  In  this  interval  the  vital  forces  are 
most  active  and  efficient ;  vitality  attains  its  maximum 
development ;  the  whole  physical  organism  is  perfected, 
and  all  its  functions  are  harmoniously  balanced.  This 
is  the  safest  and  most  favorable  period  in  which  to  take 
risks,  and  the  conclusion  is  indisputable  that  life  insur- 
ance would  be  largely  benefited  and  the  rates  much 
decreased,  if  it  could  be  limited  to  this  period,  and  to 
healthy  individuals  only. 

At  the  age  of  forty,  the  decline  of  life  usually  sets 
in ;  the  organism  develops  incipient  irregularities ;  some 
organs  fail  to  perform  their  functions  satisfactorily; 
others,  in  consequence,  are  unduly  strained  in  the 
struggle  to  maintain  life.  This  irregularity,  together 
with  a  gradual  hardening  of  the  tissues,  progresses  at 
an  unequal  and  often  dangerous  speed.  Thus  persons 
beyond  the  age  of  forty  become  the  more  liable  to 
attacks  of  organic  disease  of  the  brain,  lungs,  heart, 
liver,  bowels,  and  urinary  organs. 


EYE.  11 


Premature  Old  Age  is  also  occasionally  met  with. 
The  examiner  will  sometimes  meet  with  applicants 
whose  looks  indicate  them  to  be  ten  years  older  than 
they  really  are.  This  abnormal  feature  is  the  result,  in 
many  instances,  of  an  overtaxed  and  impaired  constitu- 
tion, previous  sickness,  or  exposure.  Hereditary  taint 
or  congenital  imperfection  may  also  produce  this  condi- 
tion. Such  persons  should  rarely  be  insured ;  unless 
all  the  other  conditions  prove  favorable,  it  will  be  better 
to  decline  every  case  of  this  kind. 

HAIK. 

The  loss  of  hair,  before  the  prime  of  life  has  passed, 
may  in  some  instances  prove  to  be  of  small  importance, 
being  simply  a  family  characteristic.  Very  often,  how- 
ever, premature  baldness  is  the  result  of  some  consti- 
tutional ailment.  Syphilis  and  kindred  diseases  are 
prolific  causes  of  baldness,  and  its  presence  frequently 
argues  against  a  favorable  risk. 

Gray  Hair  also  demands  attention.  When  care-- 
fully  investigated,  it  may  prove  to  be  merely  a  family 
characteristic.  But  where  the  person  whose  hair  has 
turned  gray  is  comparatively  young,  it  more  often 
evidences  lesion  of  the  brain. 

Individuals  having  light  or  sandy  hair  are  supposed 
to  be  more  frequently  affected  with  diabetes  than  those 
with  darker  shades. 

EYE. 

It  is  so  usual  for  the  color  of  the  eye  and  the  tem- 
perament to  be  affiliated,  that  it  has  become  a  general 
rule  to  determine  the  temperament  of  a  person  by  the 


12  TREATISE   ON   MEDICAL   EXAMINATION. 

color  of  the  eyes.  Attention  to  this  fact  is  therefore 
necessary. 

Certain  remote  diseases  are  sometimes  indicated  by 
the  expression  of  the  eye.  In  certain  cases  of  insanity 
the  eye  is  sparkling ;  in  consumption  and  anaemia  a 
pearly  conjunctiva  is  apparent;  in  softening  of  the 
brain  there  is  sluggishness;  in  intemperance,  the 
glaring  features  prevail;  in  heart  diseases  projection 
of  the  eyeball ;  and  in  Bright's  disease  there  is  more  or 
less  oedema  of  the  lower  lids. 

Proper  attention  to  the  movements  of  the  eye,  the 
contraction  and  dilatation  of  the  pupil,  is  also  enjoined. 

COUNTENANCE. 

This  is  of  considerable  importance  and  a  great  aid  to 
the  examiner,  particularly  in  the  diagnosis  of  various 
obscure  diseases.  The  color,  shape,  movements,  and 
expressions  of  the  face,  have  their  peculiar,  and,  ordi- 
narily, their  unmistakable  significance.  Yellowness 
bespeaks  an  inactive  liver ;  paleness  is  frequently  an 
indication  of  anaemia,  scrofula,  consumption,  or  cancer. 
The  lips  may  be  either  purple,  crimson,  or  pale.  The 
features  may  be  full  and  swollen  from  oedema  or  con- 
gestion, or  they  may  be  shrunken  or  contracted  from 
exhaustion.  Clear  redness  of  the  skin  shows  that  the 
blood  is  thoroughly  arterialized  and  properly  circu- 
lated. A  dark  red  or  violet  tint  invariably  indicates 
obstructed  circulation. 

In  consumption,  we  observe  a  delicate  paleness,  a  cir- 
cumscribed flush,  a  quivering  movement  of  the  lips 
and  chin  when  speaking,  a  turned  upper  lip,  long  eye- 


COMPLEXION.  13 

lashes,  and  pearly  conjunctiva?.  In  organic  disease  of 
the  heart,  the  face  is  puffed  and  of  a  dingy  hue  and  the 
flesh  under  the  eyes  swollen.  In  liver  diseases,  we  note 
a  deep  yellow  discoloration  of  the  skin,  which  measur- 
ably extends  to  the  white  of  the  eyes.  In  chlorosis,  the 
face  is  sallow  or  of  a  dingy  pallor,  greenish,  a  dark 
ring  encloses  the  eyelids,  and  in  some  cases  a  dark 
streak  is  observed  about  the  mouth.  In  kidney  affec- 
tions, the  eyelids  are  puffy,  the  skin  is  sodden  or 
waxy,  dry  and  rough,  and  the  look  downcast.  In 
intemperance,  we  observe  fullness  and  congestion  of 
the  face  and  eyes,  and  a  frightful  glare.  In  paralysis, 
there  is  the  want  of  movement.  In  insanity  the  eyes 
are  sparkling  and  restless,  and,  in  advanced  cases, 
they  have  a  wild  expression.  In  softening  of  the 
brain,  the  face  becomes  dull  and  listless,  and  the 
eyes  are  languid  and  sluggish. 

COMPLEXION. 

This  refers  particularly  to  the  skin  of  the  face.  The 
complexion  may  be  affected  by  peculiar  shades  of  color, 
sometimes  the  result  only  of  exposure,  but  more  fre- 
quently traceable  to  past  or  present  disease.  The  sal- 
low color  of  the  face  may  be  owing  to  residence  in  a 
malarial  district.  The  complexion  may  be  bronzed, 
from  exposure,  but  sometimes  it  may  be  the  result  of 
Addison's  Disease.  The  livid  face  from  imperfect  aera- 
tion of  the  blood,  the  pallid  and  sodden  skin,  may  be 
caused  by  albuminuria  and  anaemia.  The  compound 
of  rose  and  alabaster  would  indicate  the  first  stages  of 
consumption. 


14  TREATISE   ON   MEDICAL   EXAMINATION. 

TEMPERAMENT. 

The  tendency  to  overlook  this  feature  in  personal  ex- 
aminations is  without  excuse.  Every  examiner  should 
be  explicit  in  investigating  and  describing  the  tempera- 
ment of  the  applicant.  It  is  seldom  the  case  that  a 
person  is  found  whose  organism  is  so  complete  and  so 
evenly  balanced  as  not  to  exhibit  a  predisposition  to 
some  particular  disease  or  derangement  of  the  body. 
The  stronger  or  the  weaker  passions  of  men  are  largely 
productive  of  certain  well  known  results. 

Sanguine  Temperaments  are  distinguished  by 
active  mental  and  muscular  movements,  a  firmness  and 
delicacy  of  the  skin,  light  hair,  blue  eyes,  and  florid 
complexion.  These  peculiarities  indicate  that  the 
blood-making  power  predominates  in  such  persons,  and 
that  consequently  they  are  predisposed  to  all  inflamma- 
tory diseases  in  their  more  dangerous  forms. 

Nervous  Temperaments  are  usually  of  pale  com- 
plexion, sharp  and  thin  features,  and  dry  and  rough 
skin.  The  chest  is  not  likely  to  be  well  developed, 
the  breathing  is  often  very  rapid,  the  pulse  quick 
and  small,  and  the  whole  nervous  system  brisk  and 
excitable.  These  circumstances  tend  toward  apoplexy, 
paralysis,  and  other  brain  or  nervous  diseases. 

Phlegmatic  Temperaments  are  frequently,  if  not 
uniformly,  dyspeptic.  The  capacity  for  assimilation  is 
usually  feeble,  and  is  often  attended  by  languor  of  mind 
and  body.  The  skin  is  apt  to  become  pale,  showing 
that  there  is  a  defective  capacity  for  blood-making. 
These  conditions  tend,  frequently,  to  scrofula,  consump- 
tion, heart  disease,  dropsy,  and  kidney  affections. 


DEVELOPMENT.  15 

Bilious  Temperaments  are  notably  troubled  with 
derangements  of  the  liver  and  stomach,  dysentery, 
haemorrhoids,  and  fistulas.  They  suffer  also  largely 
from  rheumatism,  heart  diseases,  and  debility,  if  not  a 
total  breaking  down  of  the  constitution,  thus  rendering 
doubtful  the  chances  for  long  life. 

DEVELOPMENT. 

In  every  instance  the  examiner  should  carefully 
scrutinize  the  whole  form,  general  appearance,  and 
bearing  of  the  applicant.  He  should  note  whether 
the  person  be  robust,  the  framework  strong,  and  the 
muscular  development  large  and  duly  proportioned 
to  height.  He  should  observe  the  outline  and  forma- 
tion of  the  head,  its  prominences,  flattehings,  special 
depressions,  and  freedom  from  injury  or  questionable 
irregularities.  The  critical  examination  of  the  trunk 
should  follow,  in  order  to  ascertain  whether  or  not  the 
curves  of  the  spine  are  natural ;  whether  the  size  and 
length  of  thorax,  the  size  and  appearance  of  the  abdo- 
men, and  the  forms  of  the  upper  and  lower  extremities 
are  relatively  well  proportioned.  The  character  of 
the  nails  requires  attention,  whether  thick  or  thin, 
blue  or  pale  in  hue.  Next  note  the  nature  of  the 
skin,  whether  soft,  harsh,  tense,  shining,  or  wrinkled. 
Search  for  scars  or  marks,  the  result  of  previous 
diseases,  and  observe  their  form,  size,  and  color.  The 
existence  of  old  scars,  in  every  case,  merits  particular 
attention,  and  very  specially  when  seated  along  the 
neck  or  in  the  groin.  The  former  indicating  scrofula, 
the  latter  syphilitic  taint. 


16  TREATISE   ON   MEDICAL   EXAMINATION. 

HEIGHT. 

The  difference  in  height  has  considerable  bearing 
upon  the  acceptance  of  a  risk.  Tall  persons,  especially 
where  the  height  is  exceptional,  have  a  greater  ten- 
dency to  organic  diseases  than  those  of  medium  height. 
They  are  also  more  liable  to  rupture,  enlarged  veins, 
and  ulcers  of  the  legs.  In  them  inflammatory  diseases 
are  more  apt  to  become  chronic;  they  are  deficient  in 
the  normal  endowment  of  muscular  power  and  of  breath- 
ing activity ;  they  are  often  unequally  balanced  in 
their  organism,  and,  therefore,  prone  to  premature 
breaking  down  of  constitution. 

Let  it  be  remembered,  also,  on  the  other  hand,  that 
men  of  low  stature — clearly  below  the  average  height — 
are  frequently  disproportioned  in  physical  structure 
and  power,  and  therefore  incapable  of  great  or  pro- 
longed endurance.  Where  epidemics  are  prevalent,  the 
mortality  among  these  has  been  found  to  be  dispro- 
portionately large. 

WEIGHT. 

As  in  other  matters,  so  in  this,  the  exceptional  con- 
ditions demand  careful  consideration.  If  the  weight 
is  great  and  out  of  proportion  to  the  height,  it  argues 
against  the  acceptance  of  the  risk ;  especially  is  this  the 
case  where  the  large  accumulation  of  fat  is  of  recent 
occurrence.  But  if  traceable  to  ordinary  natural  causes, 
or  to  hereditary  predisposition,  it  may  be  overlooked, 
provided  always,  that  the  other  circumstances  are  favor- 
able. Persons  of  slender  build  or  form,  although  some- 
what emaciated,  having  a  good  family  record  and  being 


WEIGHT. 


17 


otherwise  satisfactory,  may  be  accounted  desirable  risks, 
even  after  they  have  passed  middle  life.  But  the  want 
or  loss  of  flesh  must  be  clearly  traceable  to  no  cause 
other  than  that  of  family  idiosyncracy.  Instances  may 
occur  in  which  the  examiner  will  discover  a  rapid  loss 
in  weight  without  any  apparent  constitutional  cause.  It 
will  be  well  to  reject  all  such  cases. 

The  annexed  table  represents  the  normal  weight  of 
individuals,  considered  in  relation  to  stature,  which,  by 
American  physiologists  and  the  general  experience  in 
this  country,  is  regarded  as  a  nearer  approach  to  cor- 
rectness than  any  other  heretofore  published.  A  varia- 
tion of  20  per  cent,  from  this  is  still  within  the  limits 
of  health. 

Five  feet,  or  sixty  inches,  multiplied  by  two,  gives  a 
product  of  one  hundred  and  twenty,  which,  indicative 
of  pounds,  is  accepted  as  the  standard  weight;  for  every 
inch  over  five  feet  let  there  be  added  five  pounds,  and 
we  have  the  following  results: — 


FEET. 
5 

5 
5 
5 
5 
5 
5 
5 
5 
5 
5 
6 


INCHES. 
1 

2 

3 

4 

5 

6 

7 

8 

9 

10 
11 


MEDIUM  CHEST 

POUNDS. 

MEASURE. 

125 

34.06 

130 

35.13 

135 

36.00 

140 

36.26 

145 

36.83 

150 

37.50 

155 

38.16 

160 

38.53 

165 

39.10 

170 

39.66 

175 

40.25 

180 

40.80 

18  TKEATISE   ON    MEDICAL   EXAMINATION. 

These  figures  apply  only  to  persons  under  forty 
years  of  age;  beyond  forty,  two  pounds  additional 
for  every  inch  above  five  feet  must  be  reckoned, 
when  the  following  figures  may  be  found  convenient 
for  reference : — 

FEET.  INCHES.  POUNDS. 

5  1  .  127 

5  2  134 

5  3  141 

5  4  148 

5  5  155 

5  6  162 

5  7  169 

5  8  176 

5  9  183 

5  10  190 

5  11  197 

6  204 

It  is  well  known,  also,  that  the  human  race  is,  in  a 
large  measure,  prone  to  corpulency  in  the  latter  period 
of  life,  and  therefore,  a  liberal  discretion  ought  to  be 
exercised,  when  determining  the  question  of  weight. 
Our  conclusion  is,  that  it  may  frequently  be  proper  to 
allow  as  high  as  fifteen  pounds  beyond  the  figures  in 
the  preceding  table. 

So,  also,  there  may  be  persons  who  have  a  good 
family  physical  record  with  other  favorable  features, 
whom  it  may  be  equally  proper  to  admit  even  with  a 
deficiency  of  fifteen  pounds  from  the  above  standard, 
without  fear  of  overstepping  safe  limits. 


VACCINATION.  19 

BLINDNESS. 

Persons  either  totally  blind  or  partially  deprived  of 
sight  are  more  liable  to  accidents  than  others,  and  their 
insurance,  therefore,  involves  greater  risks.  The  ex- 
aminer must  carefully  consider,  in  his  investigations, 
the  loss  of  this  important  organ,  for  the  blind  are 
constantly  exposed  to  dangers  and  injuries  which  the 
seeing  may  easily  avoid.  As  a  rule,  they  are  not  con- 
sidered favorable  risks. 

DEAFNESS. 

As  in  blindness,  so  also  in  this  case,  the  defect  is 
serious.  Deafness  renders  the  encountering  of  injury 
not  only  possible,  but  very  probable.  Although  the 
individual  may  otherwise  be  possessed  of  robust  health, 
the  loss  of  hearing  argues  badly  for  insurance.  The 
ear  may  be  as  ready  and  useful  in  detecting  danger  and 
avoiding  injury  as  the  eye.  Its  importance,  therefore, 
should  never  be  underrated  by  the  examiner.  When 
deafness  and  blindness  exist  in  the  same  person,  the 
case  is  simply  not  insurable. 

VACCINATION. 

It  is  an  admitted  fact,  which  should  be  observed  in 
every  case,  that  the  effect  of  vaccination  on  the  system 
diminishes  progressively  until  it  becomes  totally  lost. 
He-vaccination,  therefore,  becomes  imperative.  Its  ne- 
cessity should  be  insisted  on  in  the  case  of  every  appli- 
cant whose  vaccination  has  not  been  recently  and 
successfully  effected.  The  importance  of  this  measure 


20  TKEATISE   ON    MEDICAL    EXAMINATION. 

should  preclude  all  uncertainty.  In  every  doubtful 
case  the  cicatrix  should  be  carefully  examined,  and 
unless  this  be  entirely  satisfactory,  re-vaccination  should 
be  insisted  on.  All  who  have  never  been  vaccinated 
should,  with  rare  exception,  be  declined  until  they  be- 
come protected  by  this  wholesome  influence. 

SMALLPOX. 

This  contagion,  in  its  several  forms,  frequently  leaves 
lesions  which  prove  hurtful  to  the  body,  impairing  some 
of  its  important  functions  and  predisposing  to  various 
diseases.  Exciting  causes  may  already  be  apparent, 
which  tend  to  consumption,  ulceration  of  the  stomach 
and  bowels,  necrosis  of  the  bones,  and  diseases  of  the 
nervous  system.  Where  the  applicant,  however,  has 
perfectly  recovered  from  an  attack,  no  objection  need 
be  made,  provided  he  reaches  the  proper  standard  on 
all  the  other  points  of  examination. 

HERNIA. 

There  is  scarcely  any  ailment  more  generally  preva- 
lent than  this.  It  is  supposed  that  one-fifteenth  of  our 
race  is  subject  to  its  discomforts  and  perils.  In  relation 
to  sex,  fourteen  cases  out  of  fifteen  are  males,  and 
only  one  in  fifteen  females.  It  is  more  dangerous  in 
the  latter,  because  of  location  and  constitutional  deli- 
cacy. E-uptures  in  females  are  mostly  of  the  femoral 
kind  and  more  susceptible  of  strangulation  than  the 
inguinal.  All  reducible  hernias,  whether  single  or 
double,  are  considered  a  bar  to  insurance,  even  under 
the  best  adapted  trusses.  Such  applicants  should  only 


LOSS    OF   LIMB.  21 

taken  when  every  other  circumstance  proves  favor- 
able. Irreducible  hernia  may  come  under  the  examin- 
er's inspection,  and  should,  in  all  cases,  be  declined. 
Cases  of  enlarged  glands,  fatty  tumors,  retained  testes, 
or  hydrocele  are  occasionally  mistaken  for  hernia.  This 
is  an  injustice  to  both  the  applicant  and  the  company, 
and  utterly  inexcusable.  Cases  of  hernia  which  have 
been  operated  on,  whether  single  or  double,  should  be 
declined,  because  the  new  formation  is  likely  to  be 
absorbed  and  the  rupture  again  appear.  Examiners 
should  be  explicit  in  stating  whether  the  hernia  is  in- 
guinal, femoral,  or  umbilical,  and  any  complication 
attending  it. 

FISTULA. 

It  is  extremely  difficult  to  heal  this  disease,  especially 
in  consumptives.  Consumptive  applicants  should,  of 
course,  be  rejected.  If,  in  other  cases,  the  disorder  is 
large,  burrowing,  and  exhausting,  or  has  shown  obstinacy 
under  current  treatment,  it  disqualifies  the  applicant. 

Reasonable  care  should  be  used  in  determining 
whether  the  case  is  of  consumptive  origin,  or  not ;  if 
originating  from  consumption,  the  best  surgical  methods 
will  fail  to  cure.  The  examiner  should  here  recognize 
the  necessity  of  being  very  clear  and  positive  in  his 
conclusion  before  recommending  a  risk. 

LOSS  OF  LIMB. 

No  particular  objection  need  be  urged  if  the  loss 
arises  from  a  mechanical  injury.  Whilst  it  is  always 
a  disadvantage  to  the  applicant,  and  indicates  a  diminu- 


22  TREATISE   ON   MEDICAL    EXAMINATION. 

tion  of  bodily  security,  the  loss  of  a  limb  seldom  affords 
justifiable  ground  for  rejection.  But  if  the  loss  has 
resulted  from  a  malignant  disease,  such  as  caries,  ne- 
crosis, mortification,  morbid  growths,  affections  of  the 
joints,  carcinoma,  and  cachectic  deposits,  no  risk  should 
be  assumed.  All  operations,  however,  which  involve 
the  loss  of  a  large  limb,  may  tend  to  impair  the 
constitution  and  to  develop  consumption  or  other 
hereditary  diseases.  If,  therefore,  the  examination 
should  not  prove  favorable  in  all  other  respects,  the 
applicant  should  be  refused. 

OCCUPATION. 

The  business  pursued  by  the  applicant  for  insurance 
deserves  consideration.  Some  occupations  are  healthier 
than  others;  some  are  attended  with  dangers  of  greater 
or  less  degree,  and  involve  a  greater  or  less  risk  in 
every  case;  some  tend  to  the  promulgation  of  life, 
though  hereditary  taint  exists  in  the  system.  A  per- 
son of  weak  heart  may  be  insurable,  if  in  a  position 
admitting  of  the  requisite  care.  But  if  the  occupation 
is  prejudicial  to  health,  or  so  laborious  as  to  invite 
disease  and  premature  death,  the  risk  in  insuring  would 
be  far  greater.  Where,  for  instance,  the  person  with  con- 
sumptive taint  pursues  a  sedentary  occupation,  in  a  dark, 
low,  ill-ventilated  apartment,  or  is  obliged  to  work  in 
an  atmosphere  vitiated  by  gases  or  the  noxious  fumes 
from  dyestuffs,  or  freighted  with  the  dust  of  powdered 
stone  or  iron  or  other  injurious  materials,  such  as 
particles  of  wool  and  cotton,  the  applicant  should  be 
refused.  This  rule  holds  good  in  every  case  where  the 


CLIMATE.  23 


personal  examination  discloses  a  frailty  of  constitution 
or  a  tendency  to  dangerous  diseases.  If  the  applicant 
is  engaged  in  wholesome  work — take,  for  instance,  the 
case  of  a  professional  man  or  merchant — an  occasional 
attack  of  simple  catarrh  or  bronchitis  would  hardly 
warrant  his  being  rejected.  In  the  case  of  a  baker, 
exposed  to  frequent  and  violent  changes  of  tempera- 
ture, to  the  inhalation  of  flour  and  dust,  combined 
with  irregular  as  well  as  unseasonable  rest,  the  con- 
clusion would  be  exceedingly  unfavorable,  since  there 
exists  the  likelihood  that  consumption  or  serious  lung 
diseases  would  be  invited  by  the  conditions  here 
stated.  Again,  cases  may  present  themselves  where  the 
occupation  tends  to  neutralize  diseases  and  to  prolong 
the  life  of  applicants.  It  will  be  seen  from  the  above 
that  the  nature  of  a  person's  occupation  should  largely 
influence  the  conclusion  of  the  examiner.  We  need 
only  to  add,  that  caution  is  strongly  demanded  wher- 
ever application  for  insurance  comes  from  painters, 
workers  in  phosphorus  or  quicksilver,  stone-cutters, 
millers,  glass-blowers,  printers,  brewers,  confectioners, 
hatters,  chemists,  gilders,  dyers,  or  factory  and  other 
hands  laboring  under  circumstances  not  favorable  to 
health. 

CLIMATE. 

In  climate  we  find  one  of  the  most  powerful  agencies 
in  producing  as  well  as  modifying  disease.  Its  influence 
is  almost  invariably  uniform.  It  tends  either  to  prolong 
or  shorten  life,  and  influence  every  constitution,  accord- 
ing to  its  character.  From  the  infancy  of  our  race,  and 
equally  so  in  every  individual,  life'  has  shown  itself 


24  TREATISE   ON   MEDICAL   EXAMINATION. 

greatly  influenced  by  external  agencies,  and  especially 
by  those  contained  in  the  atmosphere.  The  effects 
of  heat  and  cold  on  the  classes  of  mankind  are 
generally  understood.  So,  also,  are  the  effects  of  a 
dry  or  of  a  moist  atmosphere  These  facts,  together 
with  the  dangers  attending  the  sudden  or  frequent 
transitions  from  one  extreme  to  the  other,  impera- 
tively demand  the  statement  here  made.  Certain 
diseases  are  engendered  by  the  effects  of  peculiar  clim- 
ates, whilst  others,  again,  are  removed  and  relieved  by 
the  same  agency.  It  is  to  be  hoped,  therefore,  that 
much  greater  attention  will  be  devoted  to  this  subject. 
In  all  cases  brought  under  observation,  the  examiner 
should  pay  close  attention  to  the  peculiar  constitution 
of  the  applicant,  and  ascertain,  as  far  as  possible,  what 
effect  change  of  climate  would  be  likely  to  have  on  the 
life  and  health  of  the  applicant. 

In  a  torrid  climate,  the  liver  becomes  stimulated 
to  undue  and  over-work.  The  necessary  removal  of  large 
quantities  of  carbonaceous  matter  follows,  of  course,  and 
induces  and  aggravates  diseases  of  the  liver,  kidneys, 
stomach,  and  bowels.  In  a  cold  climate,  where  the 
great  expenditure  of  animal  heat  demands  continually 
a  proportionate  supply,  the  carbonaceous  matter  is 
expelled  chiefly  through  the  lungs,  and  less  effort  is 
required  from  the  liver.  But  as  the  greater  activity  is 
imposed  upon  the  lungs,  these,  in  turn,  become  more 
liable  to  disease,  as  does  also  the  heart.  In  temperate 
climates  the  influences  noted  are  greatly  modified  and 
the  vital  organs  are  far  less  tried,  though  sudden 
changes  of  weather  are  very  apt  to  produce  inflamma- 
tory diseases,  such  as  rheumatism  and  catarrhal  affec- 


ALCOHOLISM.  25 

tions.  All  this  must  be  taken  into  consideration  when 
determining  cases  in  which  existing  diseases  or  a  pre- 
disposition to  special  disorders  may  be  unfavorably 
influenced  by  locality  or  climate. 

ALCOHOLISM. 

The  diagnosis  of  cases  involving  alcoholic  abuses  is 
often  difficult  and  perplexing.  The  applicant  inva- 
riably assumes  to  be  of  temperate  habits,  and,  whilst  he 
may  be  drinking  to  excess  and  become  so  drunken  as 
to  be  classified  in  the  list  of  the  demoralized  and  hope- 
lessly dissipated,  he  still  claims -the  virtues  of  self  con- 
trol and  moderation.  General  questions  and  answers 
are,  therefore,  insufficient;  his  personal  representations 
should  by  no  means  be  taken  as  satisfactory.  The 
examiner  must  exercise  his  utmost  skill  to  ascertain  the 
kind,  quality,  and  quantity  of  liquor  daily  and  weekly 
consumed.  He  must  further  ascertain  the  length  of 
time  during  which  the  habit  has  been  indulged,  and 
what  the  gradual  increase  of  his  potations  has  been, 
in  order  to  be  able  to  decide  whether  the  applicant  has 
not  established  the  disease  called  alcoholism.  It  will 
also  be  wise,  in  some  cases,  to  inquire  closely  into 
the  family  history,  as  the  habits  of  the  immediate 
ancestors  may  materially  influence  the  case.  When 
the  parents  have  previously  contracted  nervous  en- 
feeblement  from  excessive  indulgence  in  strong  drink, 
the  saddest  effects,  viz.:  alcoholism,  insanity,  epilepsy, 
and  numerous  other  diseases,  may  become  entailed  on 
their  offspring.  These  precautions  will,  of  course,  prove 
unnecessary  when  the  applicant's  condition  is  evidenced 
3 


26  TREATISE   ON   MEDICAL   EXAMINATION. 

in  his  own  person,  showing  a  frequent  muscular  tremor, 
coated  tongue,  fetid  breath,  flabby  and  oily  skin,  red- 
ness of  the  eyes,  impaired  appetite,  weakened  digestive 
organs,  impoverished  blood,  and  blunted  intellect  and 
perceptions. 

All  alcoholic  poison  tends  strongly  to  engender  con- 
gestive affections  of  the  brain  and  nervous  system, 
inflammation  of  the  lungs  and  heart,  gastritis  and  hemor- 
rhage from  the  stomach,  cirrhosis  of  the  liver,  Bright's 
disease  of  the  kidneys,  and  other  evils.  Indirectly,  it 
also  favors  the  early  development  of  many  infirmities 
and  diseases,  by  draining  and  impairing  the  natural 
fund  of  resistance.  It  contributes  largely  to  fatality 
in  sickness,  because  of  impaired  ability  to  endure  and  to 
overcome.  Taken  in  large  quantity,  it  may  destroy 
life  suddenly. 

Where  there  is  inclination  towards  insanity,  either 
by  transmission  or  from  other  causes,  it  may  impel  to 
suicide  or  dementia,  by  breaking  down  the  nerve  fibre. 
It  is  sometimes  followed  by  hemiplegic  paralysis. 
It  will, 'in  some  cases,  cause  the  rupture  of  a  cerebral 
artery,  the  effusion  of  blood  producing  a  sudden, 
dangerous  attack  of  apople»y.  It  is  needless,  how- 
ever, to  enumerate  more  in  the  long  train  of  evils 
following  in  the  wake  of  alcoholism,  enough  being 
here  stated  to  prove  that  persons  addicted  to  its  free  use 
are  not  suitable  subjects  for  insurance. 

It  may  be  necessary,  however,  to  add  that  alco- 
holism, in  some  of  its  stages,  may  be  mistaken  for 
paralysis,  lead  poisoning,  locomotor  ataxia,  nervous 
depression,  and  some  forms  of  dyspepsia. 

As  regards  the  man  who  engages  in  a  periodical  de- 


ALCOHOLISM. 


27 


bauch,  being  strictly  temperate  in  the  interim,  it  will  be 
observed  that  such  habits  work  impairment  of  the  con- 
stitution and  affect  the  risk  very  unfavorably.  In  the 
host  of  total  abstainers  from  alcoholic  drinks,  we  some- 
times meet  with  what  are  called  "reformed  drunkards." 
These  are  not  good  subjects  for  insurance.  Their  repent- 
ance has  frequently  come  too  late  to  serve  the  best 
interests  of  physical  constitution.  Years  of  total  abstemi- 
ousness may  fail  to  restore  the  probability  of  lengthened 
existence,  or  to  place  them  even  on  the  same  level  with 
those  who  use  spirits  in  moderation ;  and,  aside  from  the 
chances  of  relapsing  into  their  old  habits  (which  are 
by  no  means  inconsiderable),  their  constitutions  have 
often  assumed  the  singularly  treacherous  character, 
that,  while  seeming  to  enjoy  robust  health,  there  lurks 
a  dangerous  tendency  to  many  acute  diseases. 


PART  II. 

THE  CIRCULATORY  SYSTEM. 


PART  II. 


THE  CIRCULATORY  SYSTEM. 


A  great  deal  that  might  be  said  in  relation  to  this  is 
omitted  here,  because  not  pertinent  to  the  present  work. 
Acute  diseases,  such  as  myocarditis,  pericarditis,  and 
endocarditis,  are  seldom  or  never  brought  before  the  in- 
surance examiner,  and,  therefore,  do  not  demand  atten- 
tion. Our  treatise  embraces  only  chronic  lesions  of  and 
within  the  heart,  and  such  functional  symptoms  of  this 
organ  as  are  direct  and  necessary  to  our  purpose. 

PULSE. 

The  pulse  is  an  important  factor  in  determining  the 
nature  and  character  of  diseases.  Its  true  condition, 
uninfluenced  by  extraneous  circumstances,  should  first 
be  ascertained,  and  in  order  to  do  this,  both  the  mind 
and  body  of  the  applicant  should  be  in  the  most  tranquil 
condition  possible.  The  pulse  will  prove  most  rapid 
in  the  standing  position,  slower  when  sitting,  and 
slowest  when  the  body  is  recumbent.  In  the  morning, 
there  is  usually  an  increase  of  action,  both  in  force  and 
frequency,  brought  on  by  the  exercise  demanded  in 
dressing  and  eating,  and  emotional  excitement  succeed- 
ing the  relative  quiet  and  rest  enjoyed  during  sleep.  In 

31 


32  TKEATISE   ON   MEDICAL   EXAMINATION. 

females  it  is  more  rapid  than  in  males.  In  the  young  it  is 
also  quicker,  diminishing  gradually  with  the  advance 
in  years,  and  again  becoming  more  rapid  in  extreme 
old  age. 

It  may  be  possible  that  the  pulse  at  the  wrist 
is  not  satisfactory.  The  examiner,  in  that  case,  will 
resort  to  other  arteries,  in  order  to  ascertain  the  force 
of  the  heart's  action,  the  nature  of  the  arterial  impulse, 
the  tone  and  physical  character  of  the  arteries,  the 
arterial  pressure,  and  the  degree  of  excitability  of 
the  nervous  system.  The  fact  that  some  arteries  are 
large  and  others  small,  some  thin  and  distensible 
and  others  thick  and  rigid,  some  deep-seated,  others 
near  the  surface  and  easily  reached,  must  be  kept 
in  view,  since  any  of  these  peculiarities  will  prove 
important  in  disclosing  the  true  condition  of  the  pulse. 

The  average  frequency  of  the  normal  pulse  is  about 
as  follows : — 

NUMBER   OF    BEATS    PER    MINUTE. 

MALES.  FEMALES. 

Youth,  80  to  90  80  to  95 

Adult,  70  to  80  75  to  85 

Middle  life,  60  to  80  60  to  85 

Old  age,       ,  60  to  75  60  to  85 

Decrepit,  75  to  85  75  to  90 

Our  conviction  is,  that  all  applicants  of  middle  age, 
having  a  pulse  below  60  or  over  85  beats  per  minute, 
should  be  rejected.  The  only  exception  permissible 
would  be  in  cases  where  the  peculiarity  is  traceable  to 
an  extraneous  or  constitutional  agency  of  insignificant 
nature,  whilst,  at  the  same  time,  every  other  requisite 
proves  satisfactory. 


PULSE.  33 

Volume  of  Pulse  may  be  in  excess  of  the  normal, 
and  the  pulse  is  then  felt  to  strike  a  large  surface  of  the 
examiner's  finger  tip,  showing  it  to  be  strong  or  full  or 
hard.  Should  it  prove  more  limited,  striking  a  minute 
spot  of  the  finger  tip,  it  is  classed  as  thread-like  ;  if  it 
is  hard  and  small,  it  is  called  wiry.  A  full  pulse  may 
be  the  result  of  general  plethora  and  forcible  contrac- 
tion of  the  ventricles,  caused  by  hypertrophy  of  the 
heart :  in  other  cases  it  may  arise  from  inflammation : 
in  still  others,  it  may  be  due  to  the  morbid  condition  of 
the  artery  produced  by  alcohol. 

If  the  volume  is  below  the  normal  measure,  it  becomes 
known  as  the  small  or  contracted  pulse.  This  may 
arise  from  an  impoverished  condition  of  the  blood,  from 
feeble  action  of  the  heart,  or  from  a  diseased  condition 
of  the  arterial  coats. 

Regular  Pulse. — In  perfect  health  the  pulsations 
will  follow  each  other  at  regular  intervals  and  with 
thorough  precision.  This  is  the  normal  rhythm  of  the 
heart. 

Irregular  Pulse. — By  far  the  larger  number  of 
cases  of  irregular  pulse  are  from  defects  or  diseases  of 
the  heart,  more  especially  of  the  mitral  valves.  In 
some  instances  it  may  proceed  from  a  disordered 
stomach ;  in  others,  from  some  disease  in  the  nervous 
system.  It  is  the  all-important  duty  of  the  examiner  to 
ascertain  the  special  cause  of  such  variations,  for, 
according  to  the  cause,  irregularity  may  point  to  grave 
lesions,  or  be  a  symptom  of  comparatively  little  signifi- 
cance. 

Intermittent  Pulse  may  be  perceptible  at  the  wrist 
and  yet  there  may  be  no  indication  of  disease  in  the 


34  TEEATISE   ON    MEDICAL   EXAMINATION. 

region  of  the  heart.  So  again,  the  impulse  of  the  heart 
may  be  intermittent  and  yet  the  pulse  at  the  wrist  may 
be  merely  feeble.  Sometimes  we  lose  only  a  single 
beat  at  the  end  of  a  number  of  regular  beats.  An 
intermittent  pulse  will  usually  be  found  associated  with 
cardiac  complications. 

A  Soft  Pulse  is  often  styled  a  compressible  one.  It 
indicates  general  weakness.  When  combined  with 
feebleness  it  becomes  the  sign  of  prostration. 

Rapid  Pulse. — An  abnormally  rapid  pulse  may 
occasionally  come  under  notice.  It  should  then  be 
borne  in  mind,  that  such  a  condition  may  arise,  either 
from  acute  disease  on  the  one  hand  or  from  depressing 
and  debilitating  influences  on  the  other.  Some  chronic 
valvular  affections  of  the  heart  are,  at  times,  also  asso- 
ciated with  frequency  of  pulse. 

Quick  Pulse. — Here  every  beat  consumes  less  than 
its  usual  time,  without  a  corresponding  increase  in  the 
number  of  beats.  This  is  indicative  of  ventricular 
contractions  attended  with  irritation  and  debility,  and 
betokens  or  evidences  nervous  disorders. 

Slow  Pulse. — In  diseases  of  a  depressing  nature, 
and  whilst  the  system  is  free  from  excitement,  the  pulse 
will  generally  be  slow,  whereas  under  excitement  it  may 
be  very  rapid.  A  slow  pulse  may  be  found  to  originate 
in  cysts  or  tumors  pressing  upon  the  aorta.  It  is  found 
also  in  certain  neuroses  and  in  fatty  degeneration  of  the 
heart.  It  may  likewise  be  exceedingly  slow  in  the  ab- 
sence of  any  underlying  diseases  of  the  heart  or  of  the 
larger  blood-vessels.  In  such  cases  the  cause  exists  in 
the  nervous  system,  and  danger  from  apoplexy  or 
other  brain  diseases  is  threatened. 


THE   HEART.  35 

The  Jerky  Pulse. — A  modification  of  the  quick 
pulse  is  characterized  by  a  hurried,  forcible  beat,  fol- 
lowed by  a  short  and  abrupt  stop.  This  may  arise 
either  from  some  defect  in  the  aortic  valves,  causing 
regurgitation,  or  from  nervous  affections.  The  charac- 
teristic pulse  of  aortic  regurgitation  is  known  as  the 
"  water-hammer"  or  the  "  receding"  pulse. 

Should  the  examiner,  at  any  time,  discern  any  varia- 
tions, which  lead  him  to  suspect  or  believe  that  the  ap- 
plicant's pulse  is  in  an  abnormal  state,  it  will  be  his  duty 
to  repeat  the  examination  at  another  time.  The  real 
cause  must  be  determined,  and,  if  found  to  indicate  any 
abnormal  condition  or  lesion  of  the  heart,  blood-vessels, 
or  nervous  system,  it  ought  to  disqualify  the  applicant. 

THE  HEAET. 

Its  Location. — A  careful  inspection  of  the  heart  is 
required,  in  order  to  ascertain  whether  any  disease  or 
malformation  exists,  and  if  so,  to  what  extent.  The 
impulse  of  the  heart  is  often  found  changed  in  position, 
area,  and  force.  Sometimes  the  heart  is  tilted  upward 
and  outward  by  enlargement  of  the  left  lobe  of  the 
liver  ;  or  it  may  be  pushed  downward  by  simple  pleu- 
ritic effusion  or  emphysema.  Deformity  of  the  spinal 
column,  cancer  of  the  lungs,  or  aneurism  will  also  bring 
on  displacement.  Depression  of^the  heart  suggests  pre- 
vious carditis.  It  must  also  be  remembered  that,  in  rare 
cases,  displacement  of  the  heart  is  congenital.  It  is 
known  that  the  general  prognosis  of  heart  disease  is 
highly  unfavorable  to  insurance.  A  person  laboring 
under  this  affliction  is  presumed  to  be  incurable.  In 


36  TREATISE   ON    MEDICAL    EXAMINATION. 

order,  however,  to  certify  the  existence  of  organic  heart 
disease  in  the  applicant,  the  examiner  is  often  required 
to  possess  the  most  clear  and  positive  knowledge  of  the 
heart's  anatomical  structure,  and  of  its  impulse,  sounds, 
and  rhythm,  under  the  conditions  of  both  health  and 
disease. 

Valves  of  the  Heart. — This  information  is  partly 
obtainable  by  a  careful  reference  to  the  relative  location 
of  the  valves. 

The  pulmonary  valves  are  situated  immediately  be- 
hind the  junction  of  the  third  left  costal  cartilage  with 
the  sternum. 

The  aortic  valves  lie  just  below  the  pulmonary,  be- 
hind the  third  intercostal  space,  at  the  left  edge  of  the 
sternum. 

The  tricuspid  valves  are  behind  the  middle  of  the 
sternum,  on  a  level  with  the  fourth  costal  cartilage. 

The  mitral  valves  are  behind  the  third  intercostal 
space,  about  one  inch  to  the  left  of  the  sternum. 

The  distinctive  sounds  of  these  various  valves  may 
be  best  heard  in  the  following  situations : — 

Pulmonary :  in  the  second  left  intercostal  space,  near 
the  sternum. 

Aortic :  in  the  second  right  intercostal  space,  near  the 
sternum. 

Tricuspid:  at  midsternum,  above  the  ensiform  car- 
tilage. 

Mitral :  immediately  above  the  apex  beat. 
By  the  action  of  these  valves,  the  heart  is  enalbled  to 
exercise  its  inherent  power  of  dilatation  and  contraction. 
At  each  contraction  an  impulse  is  transmitted  by  the 
apex  to  the  wall  of  the  thorax. 


THE  HEART.  37 

Sounds  of  the  Heart. — In  the  production  of  the  first 
sound,  the  contraction  of  the  cardiac  muscle,  the  stroke 
of  the  heart  against  the  chest  wall,  the  closure  of  the 
auriculo-ventricular  valves,  and  the  rush  of  blood 
through  the  heart,  all  act  as  factors.  The  second  sound 
(shorter,  quicker,  and  clearer  than  the  first)  is  caused 
by  the  closure  of  the  aortic  and  pulmonary  valves. 

Rhythm. — The  rhythm  of  the  heart  comprises  the 
successive  auricular  and  ventricular  contractions  and 
the  period  of  relaxation  that  follows.  With  reference  to 
the  sounds  of  the  heart,  the  pulsation  may  be  divided 
into  four  equal  parts.  The  first  sound  occupies  two  of 
these  parts,  the  second  sound  one  part,  and  the  conse- 
quent pause  one  part. 

Abnormal  Sounds. — In  diseased  conditions  of  the 
heart,  or  under  excitement,  we  discover  certain  abnormal 
sounds  called  murmurs.  They  may  emanate  either  from 
the  interior  or  from  the  orifices  of  the  heart. 

The  Endocardial  or  Valvular  Murmur  is  either 
blowing,  grating,  rubbing,  or  musical.  It  tells  the  ear 
that  something  has  changed  or  roughened  the  surfaces 
of  the  endocardium,  or  constricted  the  orifices  of  the 
heart,  or  so  impaired  the  efficiency  of  the  valves  that 
they  allow  the  blood  to  regurgitate.  This  sound  is 
not  affected  by  pressure.  It  may  seem  remote.  It  may 
be  produced  during  the  systole  or  diastole.  It  often  ac- 
companies the  heart  sounds.  It  can  be  heard  along  the 
course  of  the  great  vessels,  and  is  usually  conducted 
around  to  the  back.  It  is  persistent  in  character. 

Pericardial  Murmur. — We  find  an  adventitious 
sound  external  to  the  heart,  that  may  often  be  con- 
founded with  endocardial  murmurs.  This  is  the  peri- 


38  TEEATISE   ON    MEDICAL    EXAMINATION. 

cardial  murmur  or  friction  sound.  It  may  be  single  or 
double.  It  is  usually  rubbing,  grazing,  or  creaking  in 
character.  It  is  superficial  and  limited  to  the  cardiac 
area.  It  follows,  rather  than  accompanies,  the  move- 
ments of  the  heart.  It  is  often  increased  in  intensity 
by  external  pressure. 

Induced  Sounds. — There  are  sounds,  also  produced 
by  the  heart,  that  are  neither  endocardial  nor  pericar- 
dial.  Whilst  themselves  perceptible  in  the  region  of 
the  heart,  they  simply  emanate  from  the  action  of  the 
heart  upon  the  lungs.  In  most  instances  they  are  in- 
spiratory,  and  cease  when  the  respiratory  movements 
are  suspended.  They  are  usually  due  to  a  dry  pleurisy 
so  situated  as  to  take  on  the  cardiac  rhythm.  A  blowing 
sound  may  originate  in  the  lung  tissue  during  cardiac 
systole.  It  may  be  added -that  a  pleuritic  friction  sound 
will  usually  become  silent  on  holding  the  breath, 
although  this  is  not  invariably  the  case,  as  in  the 
position  just  cited. 

Inflammations  of  Heart. — As  to  the  investigation 
of  acute  endocarditis  or  pericarditis  or  any  inflamma- 
tion affecting  the  muscular  and  intermingling  cellular 
tissue  of  the  heart,  little  need  be  said.  It  may  be  well, 
however,  for  the  examiner  to  bear  in  mind  that  acute 
rheumatism,  pleurisy,  pneumonia,  Bright' s  disease  of  the 
kidneys,  scarlet  fever,  drunkenness  or  other  abuses,  are 
the  ordinary  causes  of  pericarditis.  That  if  the  disease 
is  of  a  severe  nature,  its  effects  will  be  to  weaken  the 
muscular  tissue  of  the  heart,  and  quite  frequently  pro- 
duce permanent  adhesions  of  the  pericardial  surfaces. 
These  adhesions  may  interfere  with  the  free  play  of  the 
heart,  and  thus  hypertrophy  and  dilatation  may  be  in- 


THE   HEAET. 


39 


duced.  Where  chronic  lesions  are  found  to  exist,  the 
applicant  should,  under  no  circumstances,  he  accepted. 

Endocarditis. — In  endocarditis  the  symptoms  are 
so  similar  to  those  in  pericarditis,  that  only  by  the  phy- 
sical signs  can  we  accurately  distinguish  them.  In 
most  cases,  acute  rheumatism  is  connected  with  this 
complaint.  The  worst  results  are  manifested  in  chronic 
alteration  of  the  valves,  which  ultimately  conduce  to 
more  serious  lesions,  such  as  hypertrophy  and  dilata- 
tion. Any  applicant  not  perfectly  recovered  from  an 
acute  disease  of  the  heart  should  be  promptly  refused. 

Valvular  Disease  of  the  heart  is  of  common  occur- 
rence. The  valves  may  have  become  impaired  either 
by  inflammation  or  by  degeneration,  often  in  conse- 
quence of  rheumatism.  Such  changes  as  thickening, 
deposits  of  fibrous,  fatty,  or  calcareous  material,  atrophy, 
contraction,  adhesion,  and  ulceration  are  produced. 
These  lesions  are,  in  the  great  majority  of  cases,  situ- 
ated on  the  left  side  of  the  heart  at  the  mitral  and  aortic 
orifices.  Tricuspid  and  pulmonary  lesions  are  of  rare 
occurrence.  We  very  frequently  encounter  the  aortic 
obstructive  lesion,  caused  by  the  contraction  of  the 
orifice.  Then  we  have  the  mitral  and  aortic  regurgi- 
tant  lesion,  interfering  with  the  function  of  the  valves 
and  rendering  them  more  or  less  inadequate.  We  next 
discover  lesions,  which,  while  involving  neither  obstruc- 
tion nor  regurgitation,  bring  about  morbid  sounds  by 
roughening  the  surfaces  over  which  the  blood  flows. 

As  already  stated,  these  lesions  of  the  valves  give 
rise  to  sounds  or  murmurs.  Aortic  murmurs  are 
greatest  in  intensity  at  the  base  of  the  heart.  An  aortic, 
systolic  murmur  (aortic  obstructive)  is  caused  by  thick- 


40  TREATISE   ON    MEDICAL   EXAMINATION. 

ening  or  constriction  at  the  aortic  orifice,  impeding  the 
blood  in  its  exit  from  the  heart.  An  aortic,  diastolic 
murmur  (aortic  regurgitant)  is  caused  by  the  inability 
of  the  valves  to  close  accurately.  If  the  two  forms  of 
lesion  coexist,  these  murmurs  may  be  combined,  giving 
a  double  aortic  murmur ;  the  systolic  produced  by  the 
flow  of  blood  from  the  heart,  the  diastolic  by  the  re- 
gurgitation.  If  there  be  much  aortic  constriction,  the 
pulse  at  the  wrist  will  be  very  feeble  compared  with  the 
strong  impulse  of  the  heart.  The  characteristic  pulse 
of  aortic  regurgitation  has  been  already  mentioned. 

Mitral  murmurs  are  greatest  in  intensity  near  the 
apex.  The  mitral,  systolic  is  the  regurgitant  murmur  ; 
the  mitral,  obstructive  murmur  is  heard  just  before  the 
systole  and  is  timed  "  presystolic."  As  in  aortic  mur- 
murs, so  we  may  have  the  double  mitral  murmur.  It 
must  be  remembered  that  it  is  possible  to  have  valvular 
disease  without  murmurs.  This  is  especially  true  with 
regard  to  mitral  stenosis. 

There  is  one  class  of  murmurs  not  dependent  on 
valvular  lesions.  We  refer  to  the  so-called  "  hsemie" 
or  "blood  murmurs."  These  are  found  in  cases  of 
marked  anaemia  or  chlorosis.  They  are  usually  soft  in 
character,  and  best  heard  at  the  base.  They  are  systolic 
in  time.  They  are  accompanied  by  the  "  venous  hum" 
in  the  vessels  of  the  neck.  They  vary  greatly  in 
intensity,  sometimes  disappearing  entirely,  to  return 
after  a  time.  In  reference  to  this  entire  subject,  we 
observe,  that,  in  the  existence  of  any  abnormal  condi- 
tion of  the  valves,  disclosing  the  presence  or  near 
approach  of  disease,  the  safest  and  best  course  will  be 
to  decline  the  application.  The  applicant  with  an 
anaemic  murmur  will  also  be  ineligible. 


THE   HEAKT. 


41 


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42  TREATISE   ON   MEDICAL    EXAMINATION. 

Hypertrophy  of  the  heart  usually  arises  from  some 
obstruction  to  the  cardiac,  arterial,  or  capillary  circula- 
tion. Thus  it  may  be  the  result  of  valvular  lesions,  of 
aneurism,  of  pericarditis  with  adhesions,  of  Bright's 
disease,  of  emphysema,  or  of  any  other  disorder  that 
necessitates  increased  heart  action.  It  is  held  by  some 
authors  that  long-continued  functional  disturbance  may 
eventually  bring  about  hypertrophy.  In  some  cases  it 
is  congenital.  In  others  it  is  caused  by  habitual  over 
exercise.  It  may  arise  without  assignable  cause.  The 
symptoms  are  all  referable  to  the  powerfully  acting 
heart.  We  find  a  strong,  full  pulse,  pulsating  carotids, 
flushed  face,  headache,  vertigo,  and  tinnitus  aurium. 
The  area  of  cardiac  dullness  is  increased,  usually  toward 
the  left.  The  apex  beat  is  below  and  to  the  left  of  its 
normal  position.  The  impulse  is  forcible.  The  first 
sound  is  heavy,  prolonged,  and  booming,  while  the 
second  is  accentuated.  The  existence  of  cardiac  hyper- 
trophy demands  the  rejection  of  the  applicant. 

Dilatation,  or  enlargement  of  the  cavities  of  the 
heart,  may  originate  either  from  obstruction  to  the 
circulation,  or  from  weakness  of  the  muscular  walls  of 
the  heart  caused  by  fatty  degeneration  or  malnutrition. 
The  symptoms  characterizing  it  are  shortness  of  breath, 
chronic  cough,  palpitation,  disordered  digestion,  rest- 
lessness, constipation,  and  chilly  sensations.  The  pulse 
is  feeble  and  irregular.  There  is  a  constant  tendency 
to  venous  fullness  and  dropsies.  The  area  of  dullness 
is  increased.  The  impulse  is  extended,  but  feeble  and 
fluttering.  The  first  sound  is  faintly  heard,  especially 
if  the  cardiac  walls  have  undergone  degeneration.  The 
second  sound  may  be  clearer  and  more  ringing  than  in 


THE  HEAET.  43 


health.  Dilatation  is  a  progressive  disease.  Every 
case,  however  mild  the  symptoms,  must  be  unhesitatingly 
refused. 

Hypertrophy  with  Dilatation  is  a  common  condi- 
tion. According  to  the  relative  extent  of  each,  the 
symptoms  of  the  one  or  the  other  preponderate. 

Atrophy  of  the  heart  is  simply  the  wasting  of  the 
cardiac  structures  aside  from  any  degenerative  change. 
It  usually  occurs  in  the  course  of  emaciating  diseases. 
The  symptoms  are  those  of  a  weak  heart.  If  such  a 
case  should  be  presented,  it  must  be  declined. 

Fatty  Degeneration  consists  in  the  replacement  of 
the  proper  muscular  tissues  of  the  heart  by  fat  granules. 
Loss  of  muscular  power  is  the  result.  The  heart  walls 
become  soft  and  friable.  Dilatation  frequently  follows. 
The  impulse  is  very  weak  or  not  felt  at  all.  The  action 
is  irregular  or  becomes  so  upon  slight  exertion.  The 
first  sound  is  short  and  feeble,  resembling  the  second 
sound  as  ordinarily  heard.  The  pulse  also  is  feeble 
and  irregular.  It  may  be  markedly  slow.  Vertigo,  a 
feeling  of  faintness,  chilly  sensations,  severe  pain  in  the 
chest  or  region  of  the  heart  are  among  the  symptoms 
found.  There  may  be  ^  apoplectic  attacks,  witft  tempo- 
rary unconsciousness,  but  without  paralysis.  The  arcus 
senilis,  though  not  a  pathognomonic  symptom,  is  fre- 
quently associated.  Fatty  degeneration  is  not  peculiar 
to  the  stout;  still,  in  every  case  of  obesity,  where  the 
fattening  process  has  been  rapid,  the  heart  should  be 
thoroughly  examined  and  evidences  of  this  disease 
sought  for.  At  the  same  time,  let  it  be  borne  in  mind, 
that,  while  the  slow  pulse  and  fatty  heart  are  often 
found  together,  the  same  form  of  pulse  may  result  from 


44  TREATISE   ON   MEDICAL   EXAMINATION. 

disorders  of  the  vagus  nerve,  due  to  diphtheria  or 
malarial  fevers.  Also,  that  malnutrition  of  the  heart 
may  give  rise  to  symptoms  closely  resembling  those  of 
fatty  heart.  Fatty  degeneration,  of  course,  precludes  the 
acceptance  of  the  applicant. » 

Angina  Pectoris  may  occasionally  come  under  notice. 
It  is  characterized  by  intense,  paroxysmal  pain  in  the 
region  of  the  heart,  shooting  to  the  back  and  shoulder 
and  down  the  left  arm.  The  face  expresses  the  greatest 
anxiety,  and  the  patient  feels  that  death  is  impending. 
The  attack  may  last  from  a  few  minutes  to  several 
hours.  It  is  supposed  to  be  due  to  perverted  innerva- 
tion  of  the  heart.  It  is  found  with  every  form  of  heart 
disease,  most  constantly,  probably,  with  a  greater  or  less 
degree  of  fatty  degeneration.  Sometimes  it  seems  to  be 
independent  of  organic  change.  As  no  symptoms  may 
be  apparent  at  the  time  of  the  examination,  it  would  be 
possible  to  obtain  a  knowledge  of  the  existence  of  the 
disease  only  by  the  most  careful  questioning.  It  is  in- 
variably prohibitory  to  insurance,  as  sudden  death  is 
liable  to  occur  at  any  time. 

Functional  Disease  of  the  heart  calls  for  special 
attention.  While  in  all  abnormal  conditions  of  the 
heart  the  applicant  should,  as  a  rule,  be  declined,  care 
must  nevertheless  be  exercised  in  determining  between 
functional  and  organic  disorders.  The  young  and 
middle  aged,  and  also  women  at  the  climacteric  period, 
are  subject  to  functional  derangements,  in  which  palpi- 
tation, and  an  intermittent,  irregular,  and  feeble  pulse, 
associated  with  valvular  murmurs  like  those  in  organic 
diseases,  will  present  themselves  to  notice.  The  heart 
may  be  excited  to  palpitation  by  causes  other  than 


THE   HEAKT.  45 

lesions  or  diseased  structure.  The  most  alarming 
symptoms  may  be  due  merely  to  irritation  in  the  kid- 
neys, liver,  uterus,  stomach,  or  bowels.  Exciting  causes 
may  also  be  found  in  rheumatism,  gout,  mental  disturb- 
ance, dyspepsia,  anaemia,  or  even  in  the  excessive  use 
of  such  stimulants  as  alcohol,  opium,  tea,  coffee,  and 
tobacco.  These  facts  will  necessarily  engage  the  ex- 
aminer's attention,  and  a  decision  will  be  postponed 
until  farther  examination  determines  the  character  of 
the  trouble.  It  should  also  be  borne  in  mind  that  fre- 
quent palpitation  may  induce  hypertrophy,  and  that 
what  at  first  is  merely  nervous  or  functional  may  event- 
uate in  organic  disease.  Other  organs,  too,  may  be 
threatened  by  the  irregularity  of  the  blood  supply. 

Palpitation  is  less  a  disease  than  a  symptom.  When 
functional,  it  arises  either  from  deranged  innervation  of 
the  heart,  or  from  an  unhealthy  state  of  the  blood, 
which,  in  case  of  plethora,  may  be  too  rich  and  abun- 
dant, or,  in  anaemia,  may  be  too  thin  and  watery.  Wher- 
ever the  heart  itself  is  not  enlarged,  the  sounds  are 
normal.  The  murmurs,  if  they  occur  at  all,  are  easily 
distinguishable,  while  exercise  seldom  produces  an  in- 
crease of  symptoms.  Cases  of  doubtful  functional  dis- 
turbance should  by  all  means  undergo  re-examination, 
and  if  it  is  manifest  that  there  is  danger  of  the  func- 
tional becoming  organic  disease,  no  insurance  should  be 
granted. 

Arterial  System. — We  also  find  that  the  arterial 
system  evidences  the  action  of  the  heart  to  a  greater  or 
less  degree.  Strong  pulsatory  movements  in  the  arte- 
ries, especially  in  the  carotids  and  temporals,  are  occa- 
sionally noticeable.  Where  these  are  not  a  symptom 


46  TREATISE   ON   MEDICAL    EXAMINATION. 

of  hypertrophy,  they  indicate  either  anaemia,  derange- 
ment in  the  digestive  organs,  or  great  excitability  of  the 
nervous  system,  such  as  frequently  attends  uterine  affec- 
tions or  is  symptomatic  of  the  excessive  use  of  alcohol, 
tobacco,  opium,  or  other  deleterious  agents. 

Aneurism. — The  subject  of  aneurism  also  demands 
passing  attention.  The  heart  is  not  the  only  part  in 
the  circulatory  system  threatened  with  disease.  Aneu- 
rism of  the  aorta  will  occasionally  present  itself  to  the 
examiner.  This  is  readily  detected  by  an  expansile, 
pulsating  tumor  on  the  chest,  attended  with  thrill,  dull- 
ness on  percussion,  and  frequently,  also,  by  a  systolic 
and,  in  some  instances,  a  diastolic  murmur.  In  some 
cases  there  may  be  no  tumor,  only  a  little  dullness  on 
percussion,  a  faint  murmur  being  perceptible.  If  the 
arch  should  be  affected,  it  may  even  be  that  neither 
murmur  nor  dullness  is  perceptible,  and,  in  that  event, 
the  symptoms  are  mainly  due  to  pressure  upon  im- 
portant structures.  The  most  common  is  dyspnoea, 
which  often  manifests  itself  in  paroxysms  with  slight 
spitting  of  blood.  There  is  at  times  a  difference  in  the 
loudness  of  the  respiratory  murmur.  There  may  be 
difficulty  in  swallowing  attended  by  cough  and  changes 
of  voice.  Inequality  of  pulse  at  the  wrist  is  a  usual 
sign.  Add  to  these  inequality  of  the  pupils,  swollen 
veins  of  the  neck,  and  more  or  less  disturbance  in  va- 
rious organs,  and  there  will  be  no  difficulty  in  coming 
o  the  decision  to  reject  the  applicant.  The  diversity 
of  character  exhibited  in  heart  diseases  and  the  great 
importance  of  the  whole  subject  would  seem  to  demand 
some  general  rules  for  diagnosis.  We  therefore  submit 
the  following : — 


THE   HEART.  47 

1.  Distress  or  pain  about  the  heart,  often  extending 
down  the  left  arm,  does  not  necessarily  establish  the 
presence  of  organic  heart  disease,  but  it  may,  neverthe- 
less, prove  to  be  highly  important  as  a  symptom,  and 
should  therefore  be  carefully  considered. 

2.  If  the  distress  or  pain  is  brought  on  suddenly 
by  any  physical  effort,  whilst  the  stomach   is   empty 
and  undistended,  increasing  in  severity  as  the  effort 
is  persisted  in,  it  then  becomes  an  almost  unmistak- 
able proof  of  some  serious  affection  in  the  circulatory 
system. 

3.  If  flatulence   of  the   stomach   or   fullness   from 
eating  hinders  the  heart's  action   and  causes  pain,  it 
becomes  important  that  a  critical  examination  of  both 
the  heart  and  blood  vessels  should  be  instituted. 

4.  In  the  absence  of  either  suffering  or  pain  about 
the  heart,  it  is  not  impossible  for  a  dangerous  form  of 
disease  to  be  then  existing  in  the  applicant. 

5.  Pain  in  the  throat,  felt  in  heart  disease,  when 
attended  by  frequent  fluctuations  in  its  severity,  may 
help  to  show  the  real  extent  and  nature  of  the  existing 
trouble. 

6.  Loss  of  heart  force  can  be  determined  by  the  readi- 
ness with  which  the  pulse  at  the  wrist  is  suppressed, 
other  conditions  being  natural. 

7.  Pulsations  persistently  violent  are  most  frequently 
due  to  the  hypertrophy  attending  aortic  regurgitation. 

8.  It  is  a  common  condition  in  heart  disease  for  the 
lips  to  be  purplish  and  the  finger  tips  to  be  cold  and 
the  feet  to  be  swollen. 

9.  Hypertrophy  of  the  heart,  unaccompanied  by  any 
valvular  lesion,  may  proceed  from  Bright's  disease,  from 


48  TREATISE   ON    MEDICAL    EXAMINATION. 

aneurism,  from  continued  functional  disturbance,  or  from 
any  kind  of  over  action. 

10.  In  mitral  diseases  there  is  ordinarily  perceptible 
a  softness  and  irregularity  of  pulse,  whereas  in  aortic 
diseases,  it  is  hard,  jerking,  and  irregular. 

11.  In  aortic  disease  cerebral  symptoms  predominate, 
whilst   in    mitral    disease    the   pulmonary   symptoms 
prevail. 

12.  Pericardial  or  extra-pericardial  exudations  are 
ordinarily  proclaimed  by  friction  murmurs,  synchronous 
with  the  heart's  movement. 

13.  Mitral  inadequacy  is  usually  manifested  by  a 
bellows  murmur,  taking  the  place  of  the  first  sound, 
and  best  heard  over  the  apex. 

14.  A  change   in   the   quality  of  the   blood  (as  in 
anemia),  dilatation,  disease  of  the  aorta,  stricture  of 
the  aortic  orifice,  a*hd  disease  of  the  aortic  valves,  are, 
in  each  case,  indicated  by  a  murmur,  emitting  the  loudest 
sound  at  the  base,  gradually  declining  on  the  line  of 
the  large  arteries. 

15.  A   roughened   auricular   surface   of  the   mitral 
valve   or   other   mitral   obstruction  is   indicated  by  a 
murmur,  presystolic   in   time,  and  best  heard  at  the 
apex. 

16.  That   alteration    in  the   rhythm   of  the  heart, 
which  produces  a  distinct  intermission  in  its  action, 
whilst  frequently  found  even  in  healthy  persons,  sug- 
gests, nevertheless,  a  diseased  condition  of  the  valves 
or  orifices,  although  it  may  often  be  difficult  to  explain 
the  precise  cause. 

17.  Irregularity   of   the   heart    sounds,    alternating 
from  loudness  to  faintness,  from  rapidity  to  tardiness, 


THE   HEART. 


49 


wherever  it  is  permanently  established,  affords  almost 
conclusive  evidence  of  such  organic  disease  as  generally 
proceeds  from  malconstruction  of  the  mitral  valves. 

18.  Anaemic  and  functional  murmurs  are  apt  to  be 
confounded  with  the  organic.  They  are  distinguish- 
able, however,  by  their  soft,  blowing  character,  their 
uniform  association  with  the  first  sound  of  the  heart, 
their  audibility  in  several  of  the  arteries  at  the  same 
period  of  time,  their  occasional  disappearance  under  a 
tranquil  circulation,  with  their  return  during  renewed 
acceleration,  the  presence  of  anaemic  sounds  in  the 
veins  of  the  neck,  and  the  absence  of  any  general 
indications  of  organic  disease. 


PART  III. 

THE  RESPIRATORY  SYSTEM. 


PART  III. 

THE  KESPIK  ATORY  SYSTEM. 


The  act  of  breathing,  or  respiration,  is  largely  mechan- 
ical. It  consists  of  inspiration  and  expiration.  In  health 
it  should  be  easy,  regular,  and  noiseless.  The  air  em- 
ployed has  been  fairly  and  reasonably  divided  into  four 
kinds  :  first,  the  residual,  which  cannot  be  expelled  from 
the  lungs,  but  remains  after  full  and  forcible  expiration ; 
second,  the  supplementary,  or  reserve,  which  can  be 
expelled  by  forcible  expiration  ;  third,  the  breath  tidal, 
or  breathing  air ;  fourth,  the  complementary,  which  can 
be  inhaled  after  an  ordinary  inspiration. 

The  number  of  respirations  per  minute,  in  a  healthy 
adult  at  rest,  is  from  fifteen  to  twenty.  It  is  greater  in 
children,  and,  without  necessary  departure  from  health, 
is  increased  by  whatever  accelerates  the  circulation.  In 
old  age  its  frequency  diminishes,  even  when  the  pulse 
remains  at  the  normal  standard.  The  respiration  may 
be  increased  by  pain  in  the  walls  of  the  chest,  as  in 
pleurisy,  rheumatism,  neuralgia,  etc.  A  singular  con- 
stancy exists  in  the  relation  between  the  frequency  of 
the  respiration  and  the  pulse.  According  to  Dr. 
Hooker,  the  relation  is  about  one  of  the  former  to  four 
and  a  half  of  the  latter.  Any  considerable  deviation 
from  this  proportion  may  be  safely  regarded  as  an  evi- 

53 


54  TREATISE   ON   MEDICAL   EXAMINATION. 

dence  of  disease.  If  the  respiration  be  less  than  four- 
teen or  more  than  twenty  per  minute,  great  care  should 
be  taken  to  ascertain  the  cause,  and,  if  not  satisfactorily 
accounted  for,  this  fact  should  be  considered  a  barrier  to 
the  risk.  The  symptoms  presented  by  abnormal  respir- 
ation are  of  great  importance,  as  they  are  signs  of 
diseases,  not  only  of  the  lungs,  but  of  various  other 
portions  of  the  body.  Difficult  respiration  may  be 
caused  by  morbid  changes  of  the  blood,  laryngeal  and 
tracheal  obstruction,  bronchial  constriction,  chronic 
bronchitis,  pneumonia,  pleurisy,  consumption,  heart 
disease,  aneurism,  cancer  or  other  tumor  within  the 
chest,  hydrothorax,  emphysema,  Bright's  disease,  or  a 
morbid  condition  of  the  pneumogastric  nerve. 

• 

MEASUEEMENT. 

By  measurement  the  examiner  obtains  a  more  accu- 
rate knowledge  of  the  chest,  and  of  its  deviations  and 
alterations  in  size  and  form.  The  common  tape  is 
recommended  as  best  for  this  purpose,  since  it  most 
readily  adapts  itself  to  the  surface.  It  should  be 
applied  under  the  vest,  if  practicable,  and  at  about 
the  level  of  the  nipples  in  males  ;  in  females,  a  little 
above  the  mammse.  We  suggest  that  the  measurement 
should  be  noted  as  follows :  first,  during  the  largest 
inspiration ;  second,  during  forced  expiration ;  third, 
during  the  tranquil  respiration  at  about  the  middle  of 
the  inspiration.  From  the  first  and  second  measure- 
ments we  get  the  extreme  capacity  of  the  lungs,  and 
from  the  third,  the  breathing  capacity.  The  force  of 
expiration  or  inspiration  in  an  individual  may  vary 


MEASUREMENT. 


55 


somewhat  within  the  limits  of  health.  Dr.  Hutchison 
furnishes  the  following  in  regard  to  the  muscular 
power  of  inspiration  and  expiration  : — 


EXPIRATORY  POWER. 

2    inches. 


INSPIRATORY  POWER. 

1£  inches,  weak. 
2         "       ordinary. 
2?       "       strong. 
3}       "       very  strong. 
4£       "       remarkable. 


The  expiratory  power  may  be  augmented  by  habitual 
movements,  in  which  it  participates.  For  this  reason 
the  inspiratory  power  is  the  preferable  test  for  health. 
To  represent  the  vital  capacity  the  following  table  has 
been  prepared.  The  capacity  given  is  for  each  inch  of 
height  between  five  and  six  feet,  and  is  regarded  by 
Dr.  Hutchison  as  clearly  showing  health,  especially  at 
the  middle  period  of  life : — 


HEIGHT. 

VITAL   CAPACITY. 

5 

feet    0 

inches 

to 

5 

feet 

1 

inch, 

174 

cubic  inches. 

5 

"       1 

inch 

" 

5 

(4 

2 

inches, 

182 

44 

5 

"      2 

inches 

u 

5 

14 

3 

" 

190 

44 

5 

"      3 

44 

it 

5 

" 

4 

(4 

198 

« 

5 

"      4 

ft 

M 

5 

« 

5 

(4 

206 

<( 

5 

"      5 

tt 

ft 

5 

« 

6 

" 

214 

44 

5 

"      6 

11 

" 

5 

II 

7 

" 

222 

« 

5 

"      7 

K 

a 

5 

(( 

8 

44 

230 

44 

5 

"      8 

tt 

tt 

5 

" 

9 

44 

238 

»4 

5 

"      9 

K 

(( 

5 

(4 

10 

44 

246 

tl 

5 

"     10 

(I 

(( 

5 

" 

11 

" 

254 

K 

5 

"     11 

H 

« 

6 

M 

262 

(( 

By  this  we  see  that  for  every  inch  of  stature  between 
five  and  six  feet,  eight  additional  cubic  inches  of  air  are 
given  out  by  a  forced  expiration,  after  a  full  inspiration. 


56  TKEATISE   ON    MEDICAL    EXAMINATION. 

There  is  also  some  relation  between  vital  capacity 
and  weight.  The  increase  in  weight  is  simply  propor- 
tioned to  the  increase  in  height.  But  if  the  excess  of 
weight  is  due  to  corpulency,  the  vital  capacity  dimin- 
ishes in  a  marked  degree,  and  it  is  uniformly  very  low 
in  corpulent  men. 

The  influence  of  age  on  vital  capacity  is  less  percep- 
tible than  is  usually  supposed.  The  general  fact  seems 
to  stand  out,  that  the  vital  capacity  undergoes  only  a 
slight  and  gradual  increase  between  the  ages  of  fifteen 
and  thirty-five  years.  Then  it  gradually  decreases. 
The  decrease  is  more  rapid  than  was  the  increase,  and 
at  the  age  of  sixty-six  years  it  has  suffered  a  diminu- 
tion  to  about  four-fifths  of  the  maximum. 

Between  the  vital  capacity  and  muscular  vigor  the 
relation  is  not  so  close  as  is  often  thought.  Cases  are 
more  or  less  numerous  in  which  persons  of  powerful 
constitution  exhibit  a  deficiency  ;  and  others,  again,  are 
met  who,  while  not  remarkable  for  physical  strength, 
present  a  large  excess. 

CHRONIC  LARYNGITIS. 

Considerable  difficulty  exists  in  determining  the  dif- 
ferent varieties.  While  symptoms  do  not  point  to 
ulcers,  and  there  is  soundness  of  the  chest  with  a 
reasonable  share  of  good  health,  there  is  every  reason 
for  regarding  the  disease  as  only  of  the  ordinary  kind. 
But  if  of  long  continuance,  the  discharge  being  fetid, 
or  if  the  act  of  swallowing  causes  coughing  and  the 
voice  is  somewhat  broken,  or  if  the  throat  is  found  to  be 
irritable  and  ulcerated,  the  inference  is  reasonable  that, 


DIPHTHERIA.  57 

even  with  the  general  health  unimpaired,  the  disease  is 
of  a  scrofulous  or  syphilitic  nature.  Where  there  is  the 
slightest  taint  of  consumption  or  syphilis  in  the  system, 
it  decides  the  combination  to  be  necessarily  fatal,  and 
determines  the  rejection  of  the  applicant. 

CATARRH. 

Catarrhal  inflammation  of  the  mucous  membrane  of 
the  throat,  induced  by  our  variable  climate,  has  devel- 
oped itself  in  thousands  of  instances.  If  there  is  consti- 
tutional cachexia  or  hereditary  tendency  to  tuberculosis 
in  the  applicant,  there  is  sufficient  warrant  for  declining 
the  risk. 

APHONIA. 

Loss  of  voice  may  be  produced  by  certain  forms  of 
hysteria,  or  by  debility  or  paralysis  of  the  laryngeal 
muscles,  overstrained  by  speaking  or  singing.  It  also 
sometimes  proceeds  from  the  poisonous  effects  of  lead, 
belladonna,  stramonium,  etc.  It  may  now  and  then 
result  from  rheumatism,  or  may  accompany  aneurism  in 
the  upper  part  of  the  chest,  congestion  of  or  effusion 
into  the  brain,  or  other  organic  cerebral  diseases.  It  is 
closely  related  to  consumption  and  syphilis.  When- 
ever found  it  should  disqualify  for  insurance,  unless 
clearly  emanating  from  trivial  causes. 

DIPHTHERIA. 

In  its  acute  stage,  diphtheria  may  never  come  before 
the  examiner ;  but  it  may  be  otherwise  as  regards  the 
serious   effects   resulting  from  it.     It  often  gives  rise 
5 


58  TREATISE   ON   MEDICAL   EXAMINATION. 

to  consumption,  albuminuria,  dropsical  effusions,  and 
more  or  less  of  permanent  paralysis.  If  an  applicant 
has  had  diphtheria  it  is  well  to  know  it,  since  then  the 
sequelae  demand  a  thorough  consideration,  and,  if  the 
facts  ascertained  are  not  satisfactory,  it  would  be  best  to 
reject. 

CHRONIC  SOEE  THROAT. 

This  is  an  inflammation  or  thickening  of  the  mucous 
membrane  forming  the  half  arches  and  upper  part 
of  the  pharynx  and  extending  to  the  Eustachian  tubes 
and  uvula.  The  irritation  creates  a  constant  disposition 
to  clear  the  throat,  which  is  frequently  attended  by  a 
dry  laryngeal  cough.  At  times  superficial  ulcers  form 
on  the  membrane.  The  disease  may  originate  in  a 
disordered  condition  of  the  stomach,  attended  by  acid 
eructations.  In  its  most  obstinate  forms,  we  usually 
discover  a  consumptive  or  scrofulous  diathesis  to  be  the 
predisposing  cause. 

It  is  somewhat  common  among  professional  men  of 
sedentary  habits,  especially  clergymen.  The  decision 
of  the  examiner,  in  these  cases,  should  be  made  with 
particular  reference  to  the  cause  and  complications.  In 
this  connection  is  suggested  the  subject  of 

THROAT  ULCERS. 

These  are  attended  with  no  little  danger  when  of 
chronic  character.  Chronic  ulcerated  sore  throat  may 
be  idiopathic,  syphilitic,  or  tuberculous,  either  of  which 
generally  furnishes  sufficient  ground  for  the  rejection 
of  an  applicant. 


LUNG   DISEASES.  59 

LUNG  DISEASES. 

On  turning  from  the  diseases  of  the  throat  to  those 
of  the  lungs,  it  is  pre-eminently  proper  that  we  should 
here  refer  to  the  process  of  examining  the  chest.  In 
this,  of  course,  we  presume  the  examiner  to  have  a 
thorough  knowledge  of  the  location,  functions,  and 
physical  nature  of  the  healthy  organs  within.  A  care- 
ful ocular  examination  of  both  the  chest  and  back  is 
needed,  for  this  will  often  disclose  important  facts 
regarding  the  condition  of  the  thoracic  viscera.  For 
this  observation  the  applicant's  chest  should  be  bared, 
or,  in  case  of  females,  to  the  extent  of  allowing  only  a 
thin,  closely-fitting  garment  to  intervene.  The  eye 
should  then  notice  the  general  shape  of  the  chest,  also 
the  size  and  the  movement  which  it  maintains.  Some- 
times it  will  be  found  to  be  congenitally  deformed ;  at 
other  times  imperfectly  developed  ;  or  sometimes  dis- 
torted by  curvature  of  the  spine.  Many  diseases  found 
within  the  chest,  such  as  pleurisy,  hydrothorax,  pneu- 
mothorax,  emphysema,  pneumonia,  consumption,  cancer, 
and  heart  disease,  tend  to  produce  some  general  morbid 
expansion  or  contraction  or  inequality  in  the  relative 
size  of  the  two  sides.  They  also  bring  about  an 
increased  or  diminished  frequency  or  an  irregularity  of 
respiration  or  an  increased,  diminished,  or  entire  cessa- 
tion of  expansion  in  the  act  of  breathing.  This  may  be 
in  either  the  whole  chest  or  in  only  a  part.  The  proper 
understanding  of  these  things  by  the  examiner,  will 
very  much  assist  him  in  his  conclusion  as  to  whether 
the  risk  should  be  recommended  or  not. 


60  TKEATISE   ON   MEDICAL   EXAMINATION. 

THE  SOUNDS  OF  THE  CHEST. 

It  is  of  extreme  importance  that  the  examiner  should 
be  familiar  with  the  normal  sounds  of  inspiration  and 
expiration ;  for  it  is  only  by  familiarity  with  the  chest 
sounds  in  health,  that  any  deviation  can  be  recognized 
as  indicating  disease.  Should  the  existence  of  an 
abnormal  condition  at  any  point  be  discovered,  persist- 
ent effort  should  be  made  to  ascertain  all  the  facts 
respecting  the  lesion.  Auscultation  of  the  lungs  is  so 
fully  treated  in  all  works  on  physical  diagnosis,  that  it 
is  needless  to  enter  into  detail  here. 

COUGH. 

Cough  is  the  forcible  effort  of  the  expiratory  muscles 
to  rid  the  lungs  of  some  irritation  or  obstruction  to  the 
proper  performance  of  their  functions.  It  is  most 
frequently  the  symptom  of  some  such  affection  as  pha- 
ryngitis, laryngitis,  tracheitis,  diseases  of  the  lungs, 
heart,  liver,  stomach,  or  pneumogastric  nerve.  At  times, 
it  may  proceed  from  a  morbid  condition  of  the  throat,  or 
it  may  be  unconnected  with  any  physical  trouble.  If 
associated  with  organic  disease,  the  application  for  insu- 
rance ought  not  to  be  entertained.  The  cough  is  dry  and 
tight  in  early  bronchitis ;  soft,  deep,  and  loose  in  the  ad- 
vanced stages.  In  incipient  consumption  it  is  hacking. 
A  cough  in  the  morning,  soon  after  waking,  is  apt  to  be 
severe  and  persistent,  as  the  bronchial  secretions,  accu- 
mulated in  the  air  passages  over  night,  will  maintain 
irritation  until  fully  expelled.  In  such  case  it  will  be 
important  to  inquire  and  examine  into  the  cause. 


ACUTE   DISEASES   OF   THE   CHEST.  61 

DYSPNCEA. 

Dyspnoea  or  shortness  of  breath  is  almost  invariably 
the  result  of  disease.  It  may  be  prominent  and  per- 
manent in  character,  and  if  so,  it  is  a  bar  to  insurance. 
The  chief  causes  are  found  in  disease  of  the  laryrix, 
trachea,  lung  tissue,  pleura,  heart,  or  kidneys.  When 
produced  by  hydrothorax  and  oedema  of  the  lung,  or 
by  affections  of  the  mitral  valves,  or  by  Bright's  disease, 
it  should  promptly  cause  the  rejection  of  any  applicant. 
It  ma^  be,  however,  only  a  peculiarity  of  the  nervous 
system  or  the  effect  of  some  idiosyncrasy,  and  in  that 
event  it  need  not  reject,  though  a  re-examination  should 
be  made. 

ACUTE  DISEASES  OF  THE  CHEST. 

In  acute  diseases  of  the  chest,  as  in  all  acute  diseases 
of  the  respiratory  organs,  should  they  ever  come  under 
the  notice  of  the  examiner,  applicants  should  be 
peremptorily  declined  until  the  acuteness  of  the  attack 
is  passed.  Should,  in  this  latter  event,  any  lesion 
remain,  it  will  be  necessary  to  determine  its  nature.  If 
threatening,  or  causing  impairment  of  health,  it  rejects. 
Such  diseases  as  acute  pharyngitis,  laryngitis,  bron- 
chitis, pleurisy,  and  pneumonitis  do  not  universally 
establish  a  tendency  to  consumption.  When  they  do 
exist  in  chronic  form,  unqualified  proof  that  there  is 
no  tuberculous  taint  in  the  system  should  be  required 
before  recommending  the  risk. 


62  TREATISE   ON   MEDICAL   EXAMINATION. 

CHRONIC  BRONCHITIS. 

Chronic  bronchitis  may  ensue  from  repeated  attacks 
of  the  acute  form,  or  from  certain  employments,  such 
as  needle-grinding,  cotton-spinning,  stone-cutting,  glass- 
blowing,  etc.  It  may  also  be  traceable  to  organic 
disease  of  the  heart,  kidneys,  liver,  lungs,  and  stomach. 
Frequently  it  becomes  associated  with  emphysema, 
asthma,  and  consumption.  While  it  may  not  seem  to 
be  immediately  dangerous,  it  is,  at  least,  apt  to  diminish 
the  probable  duration  of  life.  The  physical  sounds  are 
the  sonorous,  sibilant,  and  mucous  rhonchi  heard 
throughout  the  chest,  in  the  absence  of  any  signs  of 
chronic  pleurisy,  chronic  pneumonia,  or  consumption.  If 
chronic  bronchitis  is  the  sequence  of  some  other  more 
serious  disease,  the  prognosis  is  unfavorable ;  and  if  the 
applicant  has  any  complication,  such  as  rheumatism, 
syphilis,  etc.,  it  must  reject,  at  least,  until  there  is 
perfect  restoration  to  health. 

EMPHYSEMA. 

Emphysema  may  affect  one  or  both  lungs  ;  usually, 
however,  both  are  involved.  It  is  a  dilatation  of  the  air 
cells,  or  an  abnormal  accumulation  of  air  within  the 
air  vesicles.  Over  exertion  or  severe  taxing  of  the 
respiratory  functions  may  produce  it,  also  chronic  bron- 
chitis, prolonged  asthma,  organic  disease  of  the  heart, 
tumors  in  the  bronchial  tubes,  diving  and  remaining 
long  under  water,  playing  on  wind  instruments,  etc. 
It  may  be  detected  by  habitual  shortness  of  breath, 
bulging  of  the  chest  walls,  increased  resonance  on  per- 


ASTHMA.  63 

cussion,  feeble  inspiratory  murmur  with  prolonged 
expiration,  diminished  vocal  resonance  and  vocal 
fremitus,  and  marked  diminution  in  the  vital  capacity. 
Sometimes  the  difference  between  forced  expiration  and 
forced  inspiration,  as  measured  by  the  tape,  will  not 
amount  to  half  an  inch.  The  heart  or  liver  may  be 
displaced.  When  but  moderately  developed,  it  may 
not  shorten  life,  but  when  strongly  marked,  it  will 
interfere  with  the  perfect  aeration  of  the  blood,  thus 
rendering  the  person  more  susceptible  to  intercurrent 
diseases  which  have  a  tendency  to  abridge  life.  For 
this  reason  such  an  applicant  is  an  undesirable  risk. 

ASTHMA. 

Asthma  is  a  paroxysmal  disease,  and  is  characterized 
by  great  difficulty  in  breathing,  brought  about  by  a 
spasmodic  constriction  of  the  bronchial  tubes.  It  is  not 
necessarily  connected  with  fever  or  organic  disease  of 
the  liver  or  heart,  as  we  may  find  instances  of  pure 
spasmodic  asthma  in  persons  otherwise  sound.  If,  how- 
ever, the  disease  has  been  of  long  duration,  continuing 
for  many  years,  the  consequences  are  liable  to  be 
serious.  In  that  case  it  becomes  the  prolific  source  of 
chronic  inflammation  and  dilatation  of  the  bronchial 
tubes,  emphysema,  oedema  of  the  lungs,  and  hemoptysis. 
At  times  the  heart  will  suffer  from  right-sided  hyper- 
trophy and  dilatation.  The  strain,  too,  may  produce 
effusion  into  the  pericardium  and  pleurae,  and,  in  severe 
forms,  congestion  of  the  brain,  giving  rise  to  coma  or 
apoplexy.  Asthma  can  readily  be%  discerned  by  the 
examiner.  The  applicant  may  willfully  or  negligently 


64  TREATISE   ON   MEDICAL   EXAMINATION. 

conceal  its  previous  existence,  but  it  will  be  easily 
detected  by  the  peculiar,  dry,  wheezing  or  sibilant 
whistle  perceptible  even  during  the  intermission  of  the 
attacks.  It  is  a  disease  that  should  reject.  The  ten- 
dency is  to  overwork  the  organs  with  which  it  is  asso- 
ciated, and  thus  shorten  life. 

PLEURODYNIA. 

This  is  a  rheumatic  affection  of  the  intercostal  mus- 
cles, and  is  characterized  by  sharp  pain,  aggravated  by 
respiration  and  other  movements  of  the  chest,  and 
unaccompanied  by  fever  or  friction  sounds.  In  a  some- 
what modified  form,  the  pain  should  be  distinguished 
from  that  caused  by  consumption,  chronic  pleurisy,  or 
even  carcinoma  within  the  chest.  The  simple  form  of 
rheumatism  or  intercostal  neuralgia  should  not  cause 
rejection ;  but  when  combined  with  evidence  of  consti- 
tutional or  organic  disease  in  the  applicant,  he  should 

be  refused  until  health  is  restored. 

• 

TUMOES  IN  THE  CHEST. 

Tumors,  whether  aneurismal,  cancerous,  or  fatty,  may 
not  have  become  known  to  the  applicant  himself.  They 
often  exist  and  are  overlooked.  When  discovered  by 
the  examiner,  they  will  be  good  and  sufficient  ground 
for  refusal.  They  are  always  likely  to  produce  pressure 
upon  the  lungs,  heart,  nerves,  or  blood  vessels.  In  that 
case  they  give  rise  to  pain,  shortness  of  breath,  palpi- 
tation, and  displacement  of  the  movable  organs.  These 
symptoms  will  in  turn  be  followed  by  interference  with 


SYPHILITIC   AFFECTION   OF   THE   LUNGS. 


65 


the  circulation,  and  also  by  bulging  of  the  ribs  and 
sternum  and  dullness  on  percussion. 


CANCEK  OF  THE  LUNGS. 

Here  we  have  retraction  of  the  affected  side.  Pain 
in  the  chest  is  much  more  common  than  in  chronic 
pneumonia.  In  the  primary  form  of  cancer,  the 
cachexia  is  not  so  distinct,  and  the  disease  is,  therefore, 
likely  to  be  confounded  with  consumption  and  chronic 
pleurisy.  It  may,  however,  be  distinguished  from  con- 
sumption by  its  slowness  of  progress,  its  slighter  con- 
stitutional disturbance,  its  limitation  to  a  single  lung, 
and  the  history  of  the  case.  A  greater  resemblance  to 
chronic  pleurisy  is  noticeable,  because  of  the  retraction 
of  the  chest  and  the  partial  displacement  of  the  heart 
and  other  organs.  Frequently  the  march  of  death  is 
slow,  but  the  result  will  be  inevitable.  When  any 
symptoms  or  signs  of  the  disease  appear,  so  as  to  con- 
vince the  examiner  of  its  existence,  he  will  unhesi- 
tatingly decline  to  insure. 

SYPHILITIC  AFFECTION  OF  THE  LUNGS. 

Syphilitic  affection  of  the  lungs  is  not  infrequently 
found.  It  is  a  known  fact  that  certain  forms  of  con- 
sumption are  the  outcome  of  changes  in  the  lung  tissue, 
due  to  syphilitic  poison.  The  syphilitic  growths  in  the 
lungs  closely  resemble  tuberculous  formations.  As  this 
form  of  lung  trouble  can  only  be  confounded  with 
tuberculosis,  the  examiner  is  perfectly  safe  in  rejecting 
the  applicant. 


66  TREATISE   ON   MEDICAL   EXAMINATION. 

CHRONIC  PNEUMONIA. 

Chronic  pneumonia  is  generally  the  consequence  of 
acute  pneumonia,  and  may  continue  for  months,  or  even 
years,  before  the  lung  returns  to  its  normal  condition. 
There  will  be  shortness  of  breath.  The  attendant 
cough  may  be  moderate,  with  or  without  expectoration. 

There  will  be  dullness  on  percussion,  together  with 
bronchial  respiration,  bronchophony,  and  increased  vocal 
resonance  and  vocal  fremitus  over  the  affected  part  of 
the  lung.  There  may  remain,  in  such  cases,  sufficient 
strength  to  enable  one  to  consider,  himself  ordinarily 
well.  If  the  deposit  is  not  connected  with  the  first 
stages  of  consumption,  there  may  be  every  prospect  of 
recovery.  But  if  there  be  evidences  of  consolidation 
with  a  tuberculous  taint,  there  is  great  apparent  danger. 
Such  an  applicant  should  not  be  accepted,  even  where 
other  circumstances  are  favorable;  at  least,  not  until 
his  lungs  are  free  from  all  deposits.  When  there  are 
evidences  of  deposit  about  the  superior  lobes  of  the 
lungs,  no  matter  from  what  cause,  there  should  be  no 
insurance. 

CHRONIC  PLEURISY. 

This  disease  may  follow  acute  pleurisy,  or  may  be 
due  to  a  sub-acute  inflammation  of  the  pleurae,  the 
early  symptoms  of  which  may  be  remarkably  latent. 
In  some  cases,  it  is  associated  with  disease  of  the 
kidneys  or  pulmonary  tuberculosis.  It  is  not  uncom- 
mon to  find  applicants  who  consider  themselves  in  fair 
health  save  for  some  gastric  or  hepatic  disturbance,  but 
who,  in  fact,  are  suffering  from  this  disease.  Here  the 


HYDROTHOKAX. 


67 


correct  diagnosis  must  rest  solely  upon  the  physical 
signs.  If  fluid  be  present,  we  find  effacement  of  the 
intercostal  spaces,  dullness  on  percussion  changing 
with  change  of  position,  feeble  or  absent  respiratory 
murmur,  and  absent  vocal  resonance  and  vocal  fremitus. 
If  adhesions  have  taken  place  we  find  retraction  of  the 
affected  side  of  the  chest,  especially  at  the  upper  part, 
and  feeble  respiration  with  prolonged  expiration  ;  some- 
times friction  sounds.  Cough  and  dyspnosa  are  more 
or  less  associated  with  both  conditions.  If  there  be 
any  constitutional  taint  or  co-existing  organic  disease, 
the  application  should  be  refused.  Simple  inflam- 
matory adhesions  should  not  be  prejudicial  if  all  else 
be  favorable;  of  course,  all  well-marked  symptoms 
must  have  subsided  before  the  applicant  should  be 
accepted. 

EMPYEMA. 

When  a  pleuritic  effusion  becomes  purulent  the 
disease  is  termed  empyema.  Added  to  the  ordinary 
signs  and  symptoms  of  effusion  within  the  chest,  there 
is  hectic  fever  with  progressive  emaciation.  Here 
rejection  is  the  invariable  rule. 

HYDROTHOKAX. 

This  term  signifies  literally  "  water  in  the  chest," 
and  implies  a  dropsical  accumulation  in  the  pleural 
cavities.  The  disease  must  not  be  confounded  with 
pleuritic  effusion.  It  is  usually  present  on  both  sides. 
It  results  from  chronic  disease  of  the  heart,  liver,  or 
kidneys,  and  is  almost  always  associated  with  other 
dropsies.  Here,  also,  there  should  be  no  insurance. 


68  TREATISE   ON   MEDICAL   EXAMINATION. 

COLLAPSE  OF  THE  LUNGS. 

This  may  be  brought  about  either  by  bronchitis  or 
compression ;  in  it  greater  or  less  portions  of  the  lungs 
are  shrunken  or  closed  to  such  an  extent  as  no  longer 
to  perform  their  functions.  The  term  itself,  in  its  most 
modified  sense,  indicates  imperfect  expansion  or  dilata- 
tion. There  is  dullness  on  percussion,  bronchial  breath- 
ing, and  increased  vocal  fremitus.  This*disease  should 
invariably  cause  refusal.  It  is  likely  to  produce  other 
serious  lesions. 

HEMOPTYSIS. 

Spitting  of  blood  may  proceed  from  the  mouth, 
fauces,  posterior  nares,  or  stomach ;  but,  in  order  to 
constitute  haemoptysis,  the  blood  must  come  in  some 
considerable  quantity  from  the  lungs.  It  is  of  the 
utmost  importance  to  determine  the  exact  origin  of  the 
blood.  If  from  the  air  passages,  it  is  preceded  by  a 
feeling  of  oppression  and  a  saltish  taste ;  it  is  raised 
without  effort  or  with  slight  cough  ;  it  is  usually  quite 
liquid,  of  bright  arterial  hue,  of  alkaline  reaction,  and 
contains  air  bubbles  in  greater  or  less  quantity.  Should 
the  hemorrhage  be  moderate  and  the  blood  have  accu- 
mulated in  the  bronchial  tubes,  coagulation  would  take 
place,  and  a  much  darker  color  be  the  result. 

The  circumstances  and  conditions  which  may  take 
part  in  the  production  of  haemoptysis  are  extremely 
various.  The  most  common  and  influential  are  the 
lifting  of  heavy  weights,  violent,  especially  sudden 
bodily  exertion,  the  free  use  of  alcoholic  stimulants, 
gout,  rheumatism,  disordered  menstruation,  inhalation 


HEMOPTYSIS. 


69 


of  gaseous  substances,  such  as  chlorine,  or  of  irritating 
particles,  organic  diseases  of  the  heart,  obstruction  of 
the  splenic  or  hepatic  circulation,  blows  on  the  chest, 
and  organic  affections  of  the  lungs.  In  the  great 
majority  of  instances  it  is  due  to  phthisis.  Hemoptysis 
will  render  the  applicant  uninsurable.  It  is  of  vital 
importance  to  ask  every  question  with  such  distinctness 
and  precision  as  to  shut  out  the  possibility  of  deception 
as  much  as  possible.  Some  will  declare  the  bleeding 
to  have  been  from  the  nose,  gums,  throat,  or  stomach, 
and  thus  the  tracing  of  the  cause  to  tubercle  may  be 
attended  with  some  measure  of  difficulty.  In  view  of 
the  seriousness  of  the  symptom,  we  suggest  that  the 
examiner  secure  unquestionable  evidence  that  the  blood 
is  not  from  the  lungs.  Should  he  fail  in  this  it  will  be 
safest  to  charge  the  trouble  to  pulmonary  mischief,  the 
forerunner  or  accompaniment  of  consumption.  Yet  it 
must  be  said  that  haemoptysis  is  not  uniformly  indica- 
tive of  the  last  named  ailment  or  so  necessarily  con- 
nected with  phthisical  tendency  as  some  suppose.  It 
so  frequently  occurs  in  pregnancy,  vicarious  menstru- 
ation, hemorrhoids,  etc.,  as  not  only  to  suggest  and  cor- 
roborate this  view,  but  even  to  warrant  the  assurance 
that  there  often  is  no  reason  why  it  should  be  regarded 
with  much  distrust,  particularly  where  it  has  resulted 
only  from  lifting,  loud  singing,  playing  on  wind  instru- 
ments, and  over  distention  of  the  stomach  in  persons 
not  predisposed  to  consumption.  These  cases  do  not 
necessarily  indicate  more  dangerous  consequences  than 
do  those  which  occur  spontaneously.  Where,  however, 
there  have  been  slight  hemorrhages  and  there  is  an 
hereditary  taint  or  a  manifestation  of  scrofula  or  con- 


70  TREATISE   ON   MEDICAL   EXAMINATION. 

sumption,  particularly  where  there  is  proclivity  to  the 
use  of  stimulants,  no  other  personal  points,  however 
favorable,  will  be  sufficient  to  warrant  acceptance. 

CONSUMPTION. 

Consumption,  often  termed  tubercular  phthisis  or 
pulmonary  consumption,  is  a  very  prevalent  and 
lamentable  disease.  It  spares  neither  rank,  condition, 
age,  nor  sex,  and,  fatal  as  it  is,  finds  its  way  too  often 
into  life  insurance  companies.  This  is  because  of  neg- 
ligence or  incompetence  or  both  on  the  part  of  the 
medical  examiner.  Of  course  there  are  difficulties  con- 
nected with  the  detection  of  this  disease,  especially  in 
its  incipiency ;  difficulties,  that  sometimes  seem  insup- 
erable. But  every  honorable  effort  must  be  made  to 
overcome  these.  Men  in  our  position  should  qualify 
themselves  thoroughly  in  order  to  grapple  with  the 
trying  and  responsible  duties  imposed  upon  them.  For 
this  reason,  among  others,  every  circumstance  which 
adds  to  the  examiner's  stock  of  information  towards 
ferreting  out  incipient  consumption  should  be  duly 
appreciated.  Nearly  all  the  cases  presented  require  a 
high  degree  of  discriminating  power.  They  are  to  be 
recognized  usually  by  the  form  of  the  body,  wanting,  as 
it  is,  in  symmetry.  The  clavicles  will  appear  more  or 
less  prominent.  There  will  also  be  flatness  of  the  chest 
in  front ;  an  unequal  height  of  the  shoulders ;  a  pale, 
sallow  complexion ;  a  deteriorated  state  of  the  constitu- 
tion ;  a  short,  dry, .hacking  cough,  scarcely  noticeable 
at  the  beginning  ;  frequent  hoarseness ;  expectoration, 
at  first  slight  and  transparent ;  pain  at  the  apices  of  the 


CONSUMPTION. 


71 


lungs  ;  chills,  not  referable  to  malaria ;  loss  of  flesh ; 
sometimes  bleeding  from  the  lungs ;  a  quick  pulse ; 
increased  temperature ;  frequent  respiration ;  shortness 
of  breath  under  the  least  exertion  ;  and  in  females,  sup- 
pression of  the  menses. 

Various  predisposing  causes  may  influence  the  devel- 
opment of  consumption,  but  pre-eminently  heredity. 
Through  one  parent  the  disease  is  often  transmitted  to 
children  ;  but  through  both  more  effectually.  In  this 
manner  whole  families  are  sometimes  swept  away  by 
this  malady  in  an  incredibly  short  space  of  time.  It 
happens  occasionally  that  the  immediate  descendants 
of  consumptive  parents  escape  the  disease,  but  retain 
the  disposition  to  it,  and  hand  it  down  to  their  offspring. 
Anything  which  has  the  effect  of  producing  permanent 
or  long  continued  debility  will  develop,  in  some  indi- 
viduals, the  consumptive  diathesis.  So,  also,  anything 
that  is  irritating,  or  that  severely  affects  the  lungs,  such 
as  pneumonia,  pleurisy,  etc.  These  may  prove  the 
exciting  cause  of  tubercle. 

No  particular  period  of  life  enjoys  special  immunity 
from  this  disease,  yet  we  find  the  age  between  sixteen 
and  forty  years  to  be  most  favorable  to  its  development. 
Following  this  comes  earlier  infancy.  Women  are 
more  readily  affected  than  men.  It  generally  occurs 
in  females  at  a  somewhat  earlier  age,  and  is,  in  their 
case,  apt  to  be  more  rapid  in  its  progress. 

Employment  or  occupation  also  exerts  an  influence 
upon  it,  those  leading  sedentary  habits  being  most  sus- 
ceptible. An  open-air  occupation,  if  in  itself  healthful, 
fortifies  against  it.  In  any  case,  a  damp  and  variable 
climate  is  more  favorable  to  consumption  than  one  that 


72  TEEATISE   ON   MEDICAL   EXAMINATION. 

is  cold  and  dry.  The  incipient  symptoms  of  consump- 
tion will  occasionally  be  found  to  simulate  those  of 
chronic  laryngitis.  Until  the  disease  is  well  advanced, 
a  laryngoscopic  examination  may  be  needed  to  deter- 
mine the  true  character  of  the  case.  There  are  cases 
in  which  phthisis  is  very  insidious  in  its  approach  and 
work.  It  will  at  times  successfully  escape  detection 
until  it  breaks  out  fully  established  with  all  its  fatal 
consequences.  Instances  may  be  found  in  young  per- 
sons where  the  general  symptoms  are  only  partially 
developed.  There  may  be  but  a  slight  flush  on  the 
cheek  and  a  chill  of  apparently  malarial  character. 
Such  persons  might  otherwise  have  been  reasonably 
considered  perfectly  healthy  up  to  the  time  when  the 
disease  fully  and  suddenly  asserted  itself.  Cases  of  this 
kind  frequently  occur,  and  physicians  of  experience 
and  merited  eminence  can  recall  instances  in  which  they 
erred  in  diagnosis,  and  treated  patients  for  malarial 
fever  until  the  disease  had  advanced  so  far  as  to  compel 
recognition. 

Although  it  is  presumed  that  the  examiner  is  familiar 
with  the  physical  signs  of  consumption,  it  may  never- 
theless be  proper  here  to  call  attention  to  some  partic- 
ular points,  and  especially  to  such  as  are  noticeable  in 
the  earlier  stages.  Percussion  under  and  over  the 
clavicle  already  shows  dullness  from  a  slight  deposit. 
If  this  dullness  is  greater  on  one  side  than  on  the 
other,  it  is  a  useful  and  important  sign,  especially  if  it 
is  greater  on  the  left  side.  Upon  auscultation  there  is 
feebleness  of  the  respiratory  sounds  in  the  parts  of  the 
lung  that  are  involved,  while  in  the  parts  not  involved 
there  may  be  puerile,  compensatory  respiration.  Should 


CONSUMPTION.  73 

the  consolidation  of  the  lung  be  more  advanced,  deep- 
seated  mucous  rales  may  be  heard  and  the  respiratory 
murmur  becomes  somewhat  rough  or  even  bronchial, 
with  a  considerable  prolongation  of  the  expiratory 
sound.  This  last  is  one  of  the  most  striking  features 
in  this  stage  of  tuberculous  deposit.  At  the  same  time 
the  inspiration  is,  in  some  cases,  interrupted,  wavy,  or 
jerking,  and  the  sounds  of  the  heart  are  more  distinctly 
heard  in  those  parts.  The  vocal  resonance  and  that  of 
cough  are  also  increased.  Another  physical  sign  is  the 
increased  vibratory  motion  of  the  chest  wall,  produced 
by  the  voice,  and  felt  by  the  hand  when  applied  to  the 
sub-clavicular  region.  We  may  also  add  that  in  this 
disease  the  temperature  is  held  to  be  of  valuable  diag- 
nostic aid,  the  heat  of  the  body,  it  is  claimed,  being 
continuously  elevated  beyond  the  normal  temperature. 
This  is  ascertainable  even  for  weeks  before  other  phy- 
sical signs  are  detected. 

The  aim  of  these  suggestions  is  simply  to  impress 
thoroughly  upon  the  mind  of  the  examiner  the  various 
points  which  develop  themselves  in  this  flattering  but 
fatal  disease ;  the  more  so  because  there  is  reason  to 
believe  that  already  there  have  escaped  the  notice  of 
highly  intelligent  and  honored  physicians  too  many 
consumptive  risks,  owing  to  neglect  of  that  thorough 
investigation  which  the  applicants  before  them  had 
undoubtedly  challenged. 


PART  IV. 

THE  DIGESTIVE  SYSTEM. 


In  this  work,  all  the  different  organs  comprised  in 
the  digestive  system  do  not  require  consideration. 
There  are  some,  however,  which  claim  attention,  viz. : 
the  mouth,  the  parotid,  sub-maxillary,  and  sub-lingual 
glands,  the  pharynx,  the  oesophagus,  the  stomach,  the 
intestine,  the  mesenteric  glands,  and  the  solid  ab- 
dominal viscera,  all  of  which  have  a  direct  bearing  on 
the  interests  of  life  insurance.  Regarding,  therefore, 
as  inadmissible  the  plan  of  arranging  in  separate 
groups  the  diseases  which  may  affect  these  organs,  we 
intend  to  make  the  necessary  discrimination,  to  exclude 
the  unessential  and  useless,  and  simply  to  present 
whatever  is  now  needed  to  meet  the  special  want. 

THE  TONGUE. 

The  tongue  may  be  natural,  pale,  red,  brown,  black, 
cold,  smooth,  furred,  or  fissured.  In  chronic  diarrhoea 
it  is  tender,  smooth,  shining,  and  frequently  studded 
with  little  ulcers.  In  diabetes  mellitus  it  is  usually 
red,  abnormally  clean,  and  fissured ;  occasionally  it  will 
be  dry  and  hard  and  of  a  brownish  color.  In  consti- 
tutional syphilis  it  will  show  inflammatory  patches, 

75 


76  TEEATISE   ON   MEDICAL    EXAMINATION. 

which  sometimes  appear  raised  and  assume  the  form 
known  as  condylomata.  In  atonic  dyspepsia  it 
becomes  broad,  pale,  flabby,  and  pitted  at  the  edges  by 
the  teeth.  In  enlargement  of  the  spleen  it  is  more  or 
less  coated  with  a  whitish  fur  and  is  markedly  pale. 
In  liver  diseases  the  coating  is  gray  or  yellowish. 

A  cold  tongue  is  an  indication  of  weakness  and 
diminished  heat  production.  It  points  to  some  pros- 
tration brought  about  by  debilitating  disease.  A  livid 
or  purple  color  of  the  tongue  mostly  succeeds  an  in- 
sufficient aeration  of  the  blood.  A  pale  tongue  tells 
of  a  deficiency  of  the  red  blood  corpuscles,  whether 
from  simple  anaemia,  malignant  disease,  or  disease  of 
the  blood-making  organs.  A  furred  tongue  accom- 
panies inflammation  of  any  organ  or  tissue.  A  brown 
or  black  tongue  evidences  an  extremely  low  condition 
of  the  system  as  well  as  great  impairment  of  the  blood. 
These  remarks  may,  in  some  instances,  be  of  practical 
value  in  looking  into  the  merits  of  cases,  since  under 
the  examiner's  eye,  the  tongue,  however  silent,  may 
prove  a  veritable  tell-tale  of  hidden  evil. 

QUINSY. 

In  severe  types  of  ulcerative  tonsillitis,  the  in- 
flammatory condition  may  extend  to  the  larynx. 
This  greatly  augments  the  danger,  and  particularly  in 
persons  having  a  tendency  to  diseases  of  a  strumous 
nature.  As  a  local  inflammation,  however,  it  is  not 
held  to  be  a  bar  to  acceptance.  It  may  be  sufficient  to 
cause  death  by  mechanical  occlusion  of  the  respiratory 
passage.  Such  a  result,  however,  is  very  rare.  It  is 


SPASMODIC   STRICTURE   OF    THE    (ESOPHAGUS.         77 

only  where  persons  are  severely  and  frequently 
afflicted  with  it,  that  it  need  be  regarded  as  un- 
favorable. 


SPASMODIC  STRICTURE  OF  THE 
(ESOPHAGUS. 

This  is  a  more  or  less  permanent  spasm  of  the  circular 
muscular  fibres  of  the  oesophagus,  causing  more  or  less 
obstruction  to  swallowing,  and  occurring  chiefly  in 
nervous  and  hysterical  women.  Uterine  derangement 
and  dyspepsia  frequently  co-exist. 

It  occurs  reflexly  in  pregnancy,  uterine  diseases, 
diseases  of  the  brain  and  cord,  and  diseases  of  the 
stomach.  Sometimes  it  occurs  as  a  symptom  of  organic 
disease  of  the  oesophagus  or  organs  adjacent.  The 
spasm  always  comes  on  suddenly,  without  much  pain, 
but  with  complete  inability  to  pass  food  into  the 
stomach. 

This  form  of  stricture  is  readily  distinguished  from 
organic  stricture  by  the  sudden  onset,  the  complete 
control  over  deglutition  in  the  interval,  the  nervous 
temperament,  the  immediate  return  of  the  bolus  of 
food,  and  the  absence  of  progressive  emaciation  and 
loss  of  strength.  The  constant  pain  of  cancer  is  also 
absent.  If  the  above  points  do  not  render  the  diag- 
nosis clear,  the  use  of  the  cesophageal  bougie  will 
show  the  spasmodic  nature  of  the  complaint.  Such  a 
case  should  not  be  accepted  till  all  signs  of  stricture 
have  disappeared. 


78  TREATISE   ON   MEDICAL   EXAMINATION. 

OKGANIC  STRICTUKE  OF  THE  (ESOPHAGUS. 

This  is  usually  caused  by  swallowing  strong  acids  or 
alkalies  or  substances  which,  by  becoming  lodged  in 
the  oesophagus,  produce  inflammation.  Cancer,  also,  is 
a  frequent  cause.  No  age  is  exempt ;  indeed,  in  rare 
cases,  the  trouble  is  congenital.  The  most  common 
seats  of  the  stricture  are  in  the  upper  third  or  at  the 
cardiac  end. 

The  symptoms  are  gradually  increasing,  persistent 
difficulty  in  swallowing  (especially  when  solid  food  is 
taken),  pain  referred  to  some  portion  of  the  tube,  and 
progressive  emaciation.  The  food  regurgitated  may  be 
mixed  with  blood  or  alkaline  mucus.  Should  any 
doubt  as  to  diagnosis  exist,  the  use  of  the  bougie  will 
settle  the  difficulty.  Pressure  on  the  oesophagus  may 
cause  symptoms  closely  simulating  stricture.  The 
applicant  should  be  rejected. 

ABDOMEN. 

The  investigation  of  quite  a  number  of  organs  is 
necessary  for  a  thorough  examination  of  this  part  of 
the  body.  Should  there  be  found  a  tumor  in  the 
abdomen,  its  nature  should  be  determined.  It  will  be 
needful  to  ascertain  whether  this  tumor  is  an  enlarged 
mesenteric  gland,  spleen,  kidney,  ovary,  or  uterus  ;  or 
whether  it  is  a  rupture,  cyst,  or  aneurism.  The  several 
organs  may  be  so  increased  in  size  as  to  fill  the  whole 
abdominal  region.  The  symmetry  of  the  parts  may 
be  destroyed  by  uterine  or  ovarian  tumors.  The  liver, 
too,  from  various  causes  may  become  enlarged.  In 


DISEASES   OF   THE   STOMACH.  79 

ascites  the  swelling  is  uniform  and  symmetrical.  At 
times  the  abdomen  may  be  retracted,  as  in  extreme 
emaciation,  lead  colic,  and  some  cerebral  diseases.  In 
case  the  examiner  finds  any  abdominal  lesion,  it  will 
be  his  duty  to  find  out  whether  it  is  of  a  temporary 
nature  or  likely  to  be  attended  with  danger.  Unless 
the  indications  are  favorable,  it  would  be  better  to 
refuse  the  applicant. 

GASTKODYNIA. 

Gastrodynia,  or  pain  in  the  stomach,  warrants  pass- 
ing attention.  The  applicant  should  be  asked  whether 
he  has  suffered  from  many  attacks,  as  it  often  proves 
to  be  the  symptom  of  serious  disease,  such  as  gastritis, 
chronic  ulcers,  cancer,  and  thickening  of  the  pyloric 
orifice.  The  pain  should,  however,  be  distinguished 
from  that  of  atonic  dyspepsia,  from  rheumatic  pains 
or  cramps  of  the  muscles  of  the  stomach  and  from 
lead  colic.  There  may  also  be  pain  in  the  stomach 
which  emanates  from  diseases  of  the  spinal  cord. 
This,  however,  may  be  distinguished  by  the  super- 
ficial gastric  tenderness,  and  by  the  presence  of  other 
painful  spots  in  the  affected  nerves.  Where  stomachic 
pain  is  other  than  transient,  it  should,  as  a  rule,  cause 
rejection  of  an  applicant. 

DISEASES  OF  THE  STOMACH. 

In  order  to  discover  the  nature  of  gastric  disease, 
the  history  of  the  case  and  the  results  of  inspection, 
palpation,  and  percussion  must  be  carefully  considered. 


80  TREATISE   ON   MEDICAL   EXAMINATION. 

If  diffused  or  localized  tenderness  exists,  it  must  be 
traced  to  its  proper  cause.  It  is  important  to  estimate 
correctly  the  size  of  the  stomach,  for  when  dilated  a 
weak  digestion  is  indicated,  and  when  contracted  there 
is  added  impaired  nutrition.  As  is  well  known,  the 
stomach  sympathizes  with  almost  every  organ  of  the 
body.  The  diseases  most  frequently  encountered  by 
the  examiner  are  dyspepsia,  dilatation,  chronic  gastritis, 
gastric  ulcer,  cancer,  and  hemorrhage. 

DYSPEPSIA. 

Dyspepsia,  or  difficult  digestion,  is  one  of  the  most 
frequent  maladies  that  will  fall  under  the  eye  of  the 
examiner. 

Many  divisions  of  this  subject  have  been  made  by 
as  many  different  authors,  but  we  will  confine  our  re- 
marks strictly  to  those  forms  that  are  met  with  most 
commonly. 

The  common  causes  are  too  much  or  too  little  food, 
the  quality  of  which  may  be  unsuited  to  the  individual, 
indiscretions  in  diet,  anaemia,  mental  worry  or  physical 
fatigue,  change  of  occupation  without  corresponding 
change  in  diet,  abuse  of  alcohol,  and  loss  of  teeth 
rendering  perfect  mastication  and  salivation  impossible. 
It  must  be  remembered  that  dyspepsia  occurs  as  a 
symptom  in  many  diseases. 

In  some  cases  of  dyspepsia  there  seems  to  present  an 
atonic  state  of  the  muscular  wall  of  the  stomach,  which 
is  the  immediate  cause  of  all  the  trouble.  Under  these 
circumstances  the  food  remains  in  the  stomach  a  long 
time  unmixed  with  the  digestive  juices  and  therefore 


DYSPEPSIA. 


81 


may  undergo  fermentative  changes.  In  other  cases  the 
nervous  symptoms  so  predominate  that  we  are  com- 
pelled to  admit  that  the  gastric  nerves  are  the  parts 
chiefly  affected.  While,  in  another  class  of  cases,  con- 
gestion of  the  mucous  membrane  of  the  stomach  with 
consequent  alteration  of  the  secretions  seems  to  explain 
the  disease  as  seen  in  certain  individuals.  It  is 
altogether  probable  that  the  excessive  or  diminished 
secretions  from  the  acid  or  peptic  glands  will  account 
for  many  of  the  symptoms  seen  in  cases  of  "acid 
dyspepsia." 

The  symptoms  that  are  often  seen  in  this  disease 
are  variable  appetite,  sometimes  anorexia;  morbid 
cravings ;  nausea ;  regurgitation,  which  may  be  simply 
the  food  ingested  or  a  liquid  having  an  acid,  alkaline, 
or  neutral  reaction,  and  which  is  then  termed  pyrosis 
or  water  brash  ;  burning  sensation  in  the  epigastrium, 
familiarly  spoken  of  as  "  heart  burn  "  ;  sense  of  weight 
and  fullness  in  the  stomach ;  irregular  action  of  the 
bowels ;  and  innumerable  sympathetic  affections.  If 
this  disease  continues,  great  mental  depression  and 
insomnia  are  apt  to  develop  and  prove  troublesome. 
This  malady  cannot  fail  to  exert  an  unfavorable  in- 
fluence upon  the  applicant's  constitution,  by  producing 
loss  of  flesh  and  strength,  which  in  turn  lessens  the 
resisting  powers  to  disease.  When  dyspepsia  is  of  long 
duration  or  attended  by  signs  of  impaired  health, 
especially  if  an  alcoholic  cause  can  be  traced,  the 
examiner  should  be  very  cautious  in  accepting  the 
risk. 


82  TREATISE   ON   MEDICAL   EXAMINATION. 

CHRONIC  GASTRITIS. 

Chronic  inflammation  of  the  gastric  mucous  mem- 
brane is  of  ordinary  occurrence.  Sometimes  it  exists 
in  a  modified  form,  but  if  present  for  a  long  period  it 
is  liable  to  cause  ulceration,  which  in  time  may 
terminate  in  perforation.  The  disease  is  pre-eminently 
the  result  of  long  standing  congestion  and  is  frequently 
accompanied  by  diseases  of  the  liver,  pancreas,  or  heart. 
It  is  largely  present  in  persons  who  indulge  freely  in 
alcoholic  liquors  and  tobacco,  and  in  those  subjected  to 
long  continued  mental  excitement.  Among  the  more 
prominent  symptoms  we  find  indigestion,  tenderness 
constant  and  limited  to  the  epigastrium,  usually  heavily 
coated  tongue,  vomiting  of  mucus  or  of  food  mixed 
with  mucus,  hot,  dry  skin,  sallow  complexion,  and 
more  or  less  emaciation.  The  rejection  of  an  applicant 
for  insurance  should  follow  when  these  symptoms  are 
found. 

ULCERATION  OF  THE  STOMACH. 

Ulceration  of  the  stomach  is  usually  associated  with 
marked  ansemia.  Its  prominent  symptoms  are  constant 
epigastric  pain  aggravated  by  food  and  especially  by 
acrid  substances,  localized  tenderness,  vomiting,  and 
hemorrhage  from  the  stomach.  The  disease  is  not 
malignant,  and  in  some  cases  the  ulcers  may  cicatrize. 
Death  may  occur  from  exhaustion,  from  hemorrhage 
caused  by  the  ulceration  of  a  large  blood  vessel,  or 
from  peritonitis  the  result  of  perforation.  Of  course, 
the  existence  of  this  disease  should  be  a  bar  to  all 
insurance. 


H^MATEMESIS.  83 

DILATATION  OF  THE  STOMACH. 

This  disease  does  not  present  itself  very  frequently, 
yet  it  warrants  brief  notice.  Cases  may  occur  in  which 
the  stomach  is  greatly  enlarged,  and  at  times  it  may 
even  fill  a  large  portion  of  the  abdominal  cavity.  In 
this  event  its  coats  are  thin  and  weak.  The  cause  is 
usually  traceable  to  an  obstruction  or  narrowing  of  the 
pyloric  orifice  which  may  arise  from  cicatrized  ulcers, 
fibrous  thickening,  cancer,  or  tumors  compressing  the 
orifice  of  the  stomach.  This  should  prove  a  bar  to 
insurance,  as  in  the  preceding  case. 

CANCER  OF  THE  STOMACH. 

Cancer  of  the  stomach  mostly  occurs  at  the  pyloric 
orifice.  It  there  forms  a  hard  growth  encircling  the 
opening  into  the  duodenum.  Its  tendency  is  to  affect 
the  neighboring  glands,  the  liver,  pancreas,  and  peri- 
toneum. The  early  symptoms  are  quite  similar  to 
those  of  chronic  gastritis.  It  is  evidently  an  hereditary 
disease,  although  it  may  be  produced  by  indigestible 
food,  alcoholic  liquors,  depressing  mental  emotions,  etc. 
It  will,  of  course,  cause  the  refusal  of  any  applicant 
for  life  insurance. 

H^EMATEMESIS. 

Hsematemesis,  or  hemorrhage  from  the  stomach, 
may  be  confounded  with  haemoptysis,  but  very  often 
the  vomit  is  mixed  with  food  and  free  from  frothiness. 
The  color,  too,  is  darkened  by  the  admixture  of  the 
juices  of  the  stomach.  This  hemorrhage  may  come 


84  TKEATISE   ON   MEDICAL   EXAMINATION. 

from  ulceration,  cancer,  or  vicarious  menstruation,  or  it 
may  proceed  from  anything  capable  of  inducing  an 
abnormal  condition  of  the  mucous  membrane  of  the 
stomach,  especially  from  congestion,  irritation,  and  in- 
flammation. These  conditions  can  be  produced  by 
alcoholic  liquors,  stimulating  food,  translation  of  gout, 
rheumatism,  suppression*  of  habitual  discharges,  and 
blows  upon  or  injuries  to  the  stomach.  It  occasionally 
may  appear  disconnected  with  organic  disease  of  either 
the  stomach  or  body.  Among  the  predisposing  causes, 
sex  and  age  may  be  given.  Women  are  uniformly  more 
liable  to  it  than  men.  The  middle  aged,  ranging  from 
twenty  to  forty  years,  are  more  subject  to  it  than  the 
young  or  quite  old.  Not  unfrequently  it  may  be  the 
effect  of  portal  congestion,  as  in  cirrhosis  of  the  liver, 
the  consequence  of  long  continued  alcoholic  stimulation. 
Hemorrhage  from  the  stomach  is  good  ground  for  the 
rejection  of  an  applicant  when  caused  by  carcinoma, 
ulceration,  or  cirrhosis  of  the  liver ;  but  when  of  a 
vicarious  nature  or  not  conjoined  to  any  appreciable 
morbid  condition,  the  risk  may  be  accepted,  provided 

it  is  otherwise  free  from  endangering  tendencies. 

i 

DISEASES  OF  THE  INTESTINES  AND 
PERITONEUM. 

In  reference  to  these  we  may  briefly  observe,  that 
the  examiner  is  seldom  required  to  decide  on  acute 
diseases  of  the  intestinal  canal.  As  he  may,  however, 
often  be  confronted  by  persons  laboring  under  chronic 
forms,  or  under  the  sequelae  of  the  acute  forms,  we 
have  particularized,  for  convenient  reference,  under  the 
following  heads : — 


CHEONIC    DIARRHOEA,  85 

CHKONIC  PERITONITIS. 

Chronic  peritonitis  is  sometimes  idiopathic,  not 
arising  from  injury  to  the  abdomen.  It  may  also  be 
the  sequel  to  an  imperfectly  cured  acute  attack,  but  is, 
however,  more  frequently  caused  by  tubercular  affec- 
tions of  the  peritoneum.  There  will  be  perhaps  slight 
pain  in  the  abdomen,  which  is  scarcely  recognized 
except  under  direct  pressure  or  when  coughing  or 
straining.  The  abdomen  may  at  times  be  swollen,  but 
in  most  cases  the  amount  of  fluid  is  small,  the  disten- 
tion  being  mainly  due  to  gas.  The  intestines  become 
glued  to  each  other  and  to  the  abdominal  walls,  and 
the  intestinal  convolutions  may  sometimes  be  traced 
externally.  The  abdomen  is  round  in  shape  and  tense, 
producing  a  clear  sound  on  percussion.  These  facts, 
in  the  absence  of  any  disease  of  the  heart,  liver,  or 
kidneys,  are  sufficient  to  enable  any  one  to  distinguish 
the  disease  from  other  dropsies.  The  tubercular  form 
is  usually  secondary  to  pulmonary  tuberculosis.  Hence 
in  all  doubtful  cases  the  lungs  should  be  carefully  ex- 
amined. It  is  always  dangerous,  and  in  the  tubercular 
form,  invariably  fatal.  It  should  cause  the  refusal  of 
all  applicants  while  it  exists. 

CHEONIC  DIARKHCEA. 

This  difficult  and  dangerous  disease  may  begin  with- 
out any  marked  symptoms  beyond  that  of  relaxed 
bowels.  It  may  result  from  malaria,  improper  food, 
the  abuse  of  purgatives,  ulceration  of  any  part  of  the 
bowels,  chronic  catarrhal  inflammation,  or  other  general 


86  TREATISE   ON   MEDICAL   EXAMINATION. 

or  local  causes.  It  frequently  accompanies  chronic 
disease  of  the  kidneys  and  liver,  tuberculosis,  chronic 
peritonitis,  disease  of  the  mesenteric  glands,  and  other 
disorders.  Sooner  or  later  it  causes  emaciation,  pros- 
tration, and  death.  Its  presence  should  prevent  insur- 
ance. 

CHRONIC  DYSENTERY. 

Chronic  dysentery  is  an  inflammation  of  the  mucous 
membrane  of  the  colon  and  rectum.  It  is  characterized 
by  tormina  and  tenesmus,  with  frequent  small  evacua- 
tions of  muco-purulent  discharges  of  blood  and  faeces 
mingled.  The  disease  is  frequently  associated  with 
chronic  diarrhoea,  or  other  wasting  diseases.  The  same 
emaciation  and  prostration  as  in  the  preceding  case 
follow  here.  In  any  form  it  unfits  the  person  for  insur- 
ance. 

HAEMORRHOIDS. 

Haemorrhoids  of  a  severe  grade  are  prone  to  impair 
the  general  health.  They  arise  from  a  want  of  exer- 
cise, leading  to  dyspepsia  with  its  train  of  concomitant 
evils,  from  constipation,  and  from  hepatic  congestion. 
Piles,  not  of  severe  form,  should  not  reject  the  appli- 
cant. Still  they  must  be  taken  into  consideration  in 
estimating  the  applicant's  eligibility. 

HABITUAL  CONSTIPATION. 

This  disorder  proceeds  from  want  of  exercise,  affec- 
tion of  the  brain,  stricture  of  large  intestine,  improper 
food,  lead  poisoning,  and  atony  of  the  colon.  It  may 


LEAD    COLIC.  87 

cause  hsemorrhoidal  tumors,  strangury,  dysmenorrhcea, 
leucorrhcea,  apoplexy,  dyspepsia,  palpitation,  dyspnoea, 
vertigo,  headache,  etc.  Whenever  detected  in  an  ex- 
treme form,  the  applicant  should  be  rejected. 

COLIC. 

Colic  may  be  bilious,  neuralgic,  spasmodic,  or  that 
form  known  as  painters'  colic.  Ordinary  attacks  of 
colic,  though  exceedingly  painful  and  often  apparently 
threatening,  seldom  prove  fatal.  Rejection  of  an  appli- 
cant becomes  advisable  only  where  it  is  of  frequent 
occurrence,  and  dependent  upon  some  serious  condition. 

LEAD  COLIC. 

Lead  colic,  by  repeated  attacks,  renders  its  subjects 
more  and  more  susceptible  to  it.  Even  a  slight  exposure 
will  frequently  induce  a  return.  It  readily  assumes  a 
chronic  form,  which  may  run  through  years  of  suffer- 
ing. In  that  case  there  may  be  defective  nutrition, 
general  emaciation,  enfeebled  circulation,  a  pale  and 
sallow  skin,  swelling  of  the  lower  extremities,  abdom- 
inal dropsy,  effusion  in  the  pleura,  impaired  hearing  and 
vision,  palsy  of  the  upper  extremities,  Bright's  disease, 
epilepsy,  and  mental  imbecility.  Persons  exposed  to 
lead  influences,  and  having  had  the  disease,  should  dis- 
continue their  occupation.  A  refusal  to  do  so  should 
disqualify  them  for  insurance. 


88  TKEATISE   ON   MEDICAL   EXAMINATION. 

THE  LIVEE. 

The  liver  might  have  been  grouped,  together  with  the 
solid  abdominal  viscera,  under  a  separate  section.  But 
as  the  spleen  comes  properly  under  the  head  of  blood- 
making  organs,  and  as  it  is  desired  to  make  a  distinct 
section  of  the  urinary  organs,  and  also  as  the  liver  and 
pancreas  play  such  a  prominent  part  in  digestion,  it 
seems  advisable  to  include  the  latter  two  under  this 
head. 

The  liver  has  an  influential  bearing  in  life  insurance, 
as  upon  its  perfect  action  depends  so  much  in  matters 
of  health. 

The  liver  is  increased  in  size  in  fatty  and  amyloid 
degeneration,  hydatid  tumor,  abscess,  cancer,  congestion, 
and  acute  hepatitis.  It  is  diminished  in  size  in  cirrhosis 
and  atrophy.  In  order  to  obtain  the  proper  information 
and  become  assured  fully  as  to  its  real  condition,  the 
examiner  must  place  the  applicant  on  his  back,  with 
the  knees  drawn  up  and  the  abdominal  muscles  relaxed. 
The  tips  of  the  fingers  should  be  applied  just  below  the 
border  of  the  ribs,  and  the  applicant  required  to  make 
a  full  inspiration  and  expiration.  By  this  the  examiner 
will  be  able  to  feel  the  lower  surface  of  the  liver  and 
ascertain  whether  it  is  smooth  or  nodular.  Finally,  by 
percussion,  he  will  be  able  to  map  out  its  size. 

FATTY  DEGENERATION  OF  THE  LIVER. 

Fatty  degeneration  of  the  liver  produces  uniform 
enlargement  of  the  organ.  There  are  no  circumscribed 
bulgings,  but  the  shape  is  unchanged.  It  never  gives 


CANCER   OF   THE   LIVEK.  89 

rise  to  dropsy,  and  is  not  attended  by  any  visible  en- 
largement of  the  superficial  veins.  On  palpation  there 
will  be  easily  detected,  provided  the  abdominal  walls  be 
not  too  thick,  a  soft,  cushion-like  enlargement,  even  as 
low  down  as  the  umbilicus.  The  tumor  is  never  tender 
on  pressure.  On  percussion,  there  is  a  flat  sound  over 
the  surface  of  the  abdomen  corresponding  to  the  enlarge- 
ment. This  form  of  liver  disease  is  most  frequently  the 
result  of  pulmonary  tuberculosis  or  intemperance.  The 
diagnosis  is  somewhat  difficult,  but  when  the  case  is 
plain,  there  should  be  no  insurance. 

AMYLOID  DEGENERATION  OF  THE  LIVER. 

When  amyloid  liver  exists,  there  is  usually  present 
a  history  of  syphilis,  of  bone  disease,  or  of  long-continued 
suppuration.  The  liver  is  apt  to  be  larger  than  in  fatty 
degeneration  ;  indeed,  this  uniform  enlargement  may  be 
so  great  that  the  liver  may  occupy  the  greater  portion 
of  the  abdominal  cavity.  Pain  and  tenderness  are 
absent.  Dropsy  may  be  present,  but  is  more  frequently 
absent.  Sometimes  there  is  jaundice.  Similar  disease 
of  spleen  and  kidneys  usually  co-exists  with  the  hepatic 
affection.  The  applicant  must  be  refused. 


CANCER  OF  THE  LIVER. 

In  hepatic  cancer  we  find  an  unevenly  enlarged, 
nodular,  tender  liver.  It  is  a  disease  pre-eminently  of 
middle  and  advanced  life.  When  it  has  reached  a  point 
for  positive  diagnosis,  there  are  marked  cachexia,  emacia- 
tion, and  disorders  of  digestion.  Jaundice  and  dropsy 


90  TREATISE   ON   MEDICAL   EXAMINATION. 

may  or  may  not  be  present.     Cancer  of  other  organs 
frequently  coexists. 

Of  course  there  should  be  no  insurance. 

HYDATID  TUMOES. 

Hydatid  tumors,  or  cysts,  of  the  liver,  when  small,' 
defy  detection  under  physical  investigation,  but  when 
large  and  superficial  they  can  be  readily  felt  on  external 
examination.  In  some  instances  they  compress  the 
portal  vein  or  vena  cava,  causing  ascites  and  oedema  of 
the  legs.  On  percussion  and  palpation  fluctuation  is 
discernible.  Occasionally,  when  very  large,  the  tumor 
will  press  on  the  heart  and  diaphragm,  thereby  inducing 
cough  and  palpitation.  Where  hydatid  tumors  exist 
the  applicant  should  not  be  accepted. 

CHRONIC  HEPATITIS. 

Symptoms  are  irregular  stools,  disordered  stomach,  a 
bitter  and  disagreeable  taste,  a  furred  tongue,  a  turbid 
or  jaundiced  appearance  of  the  eyes  and  skin,  harsh 
and  dry  skin,  highly  colored  and  bilious  urine,  a  short, 
dry  cough,  depression  of  spirits,  and  general  emaciation. 
Added  to  these  symptoms,  we  find  the  liver  uniformly 
enlarged  and  harder  than  normal.  The  disease  is  chiefly 
found  in  hot  climates.  Its  origin  is  traceable  to  intoxi- 
cating liquors,  tobacco,  metastasis  of  gout  or  rheumatism, 
suppression  of  accustomed  discharges,  and  atmospheric 
changes.  Wherever  it  appears  in  an  applicant,  rejection 
must  follow. 


CIRRHOSIS. 


CIRRHOSIS. 


91 


Cirrhosis,  or  interstitial  hepatitis,  is  a  chronic  in- 
flammation of  the  connective  tissue  of  the  liver.  It  is 
chiefly  the  result  of  rum  drinking.  The  organ  is  hard, 
tough,  and  leathery,  and  usually  much  reduced  in  size, 
especially  the  left  lobe,  which  is  often  shriveled  into  a 
mere  membranous  appendage.  The  surface,  when  the 
capsule  is  removed,  often  exhibits  protuberances  of 
various  sizes,  and  for  this  reason  it  has  been  denomi- 
nated "  hob-nailed."  The  increased  connective  tissue 
impinges  on  the  ramifications  of  the  venae  portae  in  the 
liver,  causing  all  the  blood  vessels  of  the  portal  system 
to  become  engorged.  Hence  the  serum  exudes  into  the 
cavity  of  the  peritoneum,  producing  dropsy.  The  spleen 
may  be  increased  in  size,  and  the  mucous  membrane  of 
the  stomach  and  bowels  so  much  congested,  that  severe 
hemorrhage  ensues.  The  symptoms  of  cirrhosis,  in  its 
early  stages,  are  not  strongly  marked ;  its  existence, 
then,  is  rather  to  be  inferred  than  asserted.  There  is  a 
tendency,  as  a  rule,  to  constipation,  a  dry  skin,  highly- 
colored  urine,  albuminuria,  an  irregular  appetite,  and 
nervous  irritability.  On  account  of  impeded  circulation 
through  the  liver  from  compression,  we  may  discover,  as 
a  positive  symptom,  an  enlargemant  of  the  superficial 
veins  of  the  abdomen.  The  existence  of  the  disease  is 
invariably  a  bar  to  insurance. 


92  TEEATISE   ON   MEDICAL   EXAMINATION. 

JAUNDICE. 

Here  we  find  yellowness  of  the  skin  and  conjunctiva, 
bile  present  in  the  urine,  and  clay-colored  stools.  There 
is  more  or  less  itching  and  harshness  of  the  skin. 
Emaciation,  loss  of  appetite,  constipation,  and  disorders 
of  digestion  also  present  themselves  as  symptoms.  The 
disease  may  be  caused  by  closure  of  the  bile  ducts  (as 
by  gall  stones,  catarrhal  inflammation,  or  pressure),  by 
certain  poisons,  or  by  disease  of  the  hepatic  cells.  Ac- 
cording to  the  cause,  it  is  temporary  or  permanent.  It 
is  frequently  a  symptom  of  chronic  liver  trouble.  The 
consideration  of  the  applicant  should  be  postponed  till 
all  jaundice  has  disappeared. 

THE  PANCEEAS. 

This  is  a  deep-seated  organ,  or  gland,  which  is  rarely 
the  seat  of  disease.  The  symptoms  of  its  morbid  con- 
ditions are  usually  obscure.  For  this  reason  an  accurate 
diagnosis  can  only  be  effected  under  difficulty.  It  may, 
in  the  course  of  an  examiner's  experience,  be  discovered 
to  be  in  an  enlarged  state.  If  so,  from  whatever  cause, 
the  risk  should  uniformly  be  declined. 


PART  Y. 

THE  URINE   AND   GENITO 
URINARY  ORGANS. 


PART  V. 

THE  URINE  AND  GENITO- 
URINARY ORGANS. 


THE  UEINE. 

We  assume  that  the  physicians  are  conversant  with 
the  normal  and  abnormal  states  of  the  urine.  The  im- 
portance of  regarding  these  conditions  in  tracing  latent 
and  insidious  diseases  has  never  been  so  justly  and 
generally  admitted  as  at  present.  It  would  appear  to 
us  almost  fatal  to  the  complete  success  of  any  practi- 
tioner, not  to  heed  duly  the  faithful  monitor  that  bears 
through  and  out  of  the  system  the  impress  and  influence 
of  systemic  disorders.  But  when  the  physician  becomes 
the  examiner  for  life  insurance,  and  is  assigned  a  place 
in  which  the  weightiest  interests  are  at  stake,  in  so  far 
as  public  organizations,  families,  and  private  individuals 
are  concerned,  and  in  which  he  is  entrusted  with  the 
decision  in  cases  that  call  for  the  minutest  and  most 
exhaustive  investigation,  then,  we  maintain,  there  is  no 
apology  for  the  lack  of  any  requisite  information  which 
the  responsibility  of  his  position  demands.  All  super- 
cilious self-sufficiency  is  highly  criminal  in  this  position, 
where  every  lurking  danger  needs  to  be  detected,  and 
every  barrier  to  be  carefully -estimated. 

95 


96  TREATISE   ON   MEDICAL   EXAMINATION. 

It  is  no  less  clear,  also,  that  certain  facts  and  points 
will  sometimes  escape  attention,  which  above  all  others 
had  merited  the  examiner's  consideration.  We  feel  the 
more,  therefore,  the  propriety  as  well  as  necessity  of 
subjoining  the  following  synopsis  of  the  chemical  and 
microscopical  analysis '  of  the  urine.  We  present  this 
in  order  to  furnish  a  safeguard  against  the  passage  and 
approval  of  any  case  in  which  existing  disease  may  be 
suspected,  and  which  might  be  traced  and  identified  by 
the  method  indicated.  It  will  be  best  for  the  examiner 
to  have  for  examination  a  specimen  of  the  urine  first 
passed  after  rising  in  the  morning.  Care  should  be 
taken  to  have  well-rinsed  and  clear  bottles,  holding  from 
three  to  six  ounces.  It  will  then  be  proper  first  to  ob- 
serve the  color ;  next  its  particular  odor,  taste,  reaction, 
specific  gravity;  presence  or  absence  of  albumen  and 
sugar,  and  the  result  of  microscopic  examination,  together 
with  inquiry  as  to  the  quantity  passed  in  twenty-four 
hours. 

Every  examination  should  take  place  within  twelve 
hours  after  the  urine  has  been  evacuated.  The  exami- 
nation of  the  sediment  under  the  microscope,  however, 
is  most  advantageously  made  after  the  specimen  has 
stood  in  a  conical  glass  between  twelve  and  twenty-four 
hours.  When  urine  is  sent  from  a  distance  the  bottle 
should  be  filled  up  to  the  cork,  so  that  there  will  be  no 
air  between  the  liquid  and  the  cork,  and  to  this  might 
be  added  ft  small  quantity  of  salicylic  acid. 


ODOR   OF   URINE.  97 

COLOR. 

The  co lor  of  urine  will  vary  in  healthy  persons,  from 
a  pale  to  a  straw  or  clear  amber  yellow,  or  even  to  a 
yellowish-red  tint.  It  will  be  affected  by  the  amount 
discharged — the  larger  the  quantity  the  paler  it  will  be, 
and,  vice  versa,  the  smaller  the  quantity  the  deeper  the 
hue.  During  sickness  or  disease  it  will  show  a  some- 
what singular  variety  of  colors,  including  pale  yellow, 
green,  red,  blue,  etc.  The  effects  on  the  urine  of  the 
administration  of  some  vegetable  and  mineral  substances 
are  also  prominently  noticeable.  Thus,  a  golden  yellow 
is  produced  by  santonine,  and  a  reddish  hue  by  logwood 
and  madder.  There  may  be  present  in  the  urine  ab- 
normal coloring  agents,  such  as  bile  and  hsematin. 

A  pale  condition  may  be  caused  by  diabetes,  polyuria, 
anemia,  hysteria  and  other  nervous  disorders.  In  some 
instances  it  may  even  prove  to  be  a  healthful  and  most 
favorable  symptom. 

ODOE. 

The  odor,  when  the  urine  has  been  quite  recently 
voided  and  when  still  warm,  is  sweetish  and  aromatic. 
This  becomes  changed,  after  the  cooling  process,  to  what 
is  generally  termed  a  urinous  smell.  There  are  condi- 
tions, however,  which  may  materially  affect  the  odor. 
Various  kinds  of  food  and  drink  sometimes  so  impress 
the  urine  with  their  peculiar  character  as  to  fee  notice- 
able in  its  exhalations.  Certain  medicinal  agents  may 
accomplish  the  same  thing ;  as,  for  instance,  the  odor  of 
violets,  caused  by  the  internal  use  of  turpentine.  Then, 
too,  certain  affections,  such  as  Bright's  disease,  diabetes, 


98  TREATISE   ON    MEDICAL   EXAMINATION. 

janndice  and  some  of  the  bladder  affections,  have  pecu- 
liarities of  their  own. 

TASTE. 

The  taste,  when  the  urine  is  healthful,  is  invariably 
of  a  saltish  and  bitter  character.  Where  there  is  dis- 
order and  where  abnormal  conditions  clearly  exist,  it 
will  greatly  vary.  In  diabetes  it  will  be  sweet,  while 
in  jaundice,  on  the  contrary,  it  will  have  a  bitter  char- 
acter. Under  diseased  conditions  it  will  be  changed 
both  by  the  nature  of  the  attack  and  the  condition  of 
the  individual,  which  fact,  together  with  gathered 
experience,  will  contribute  readily  toward  correct  con- 
clusions. 

KEACTION. 

The  reaction  of  urine  is  soon  determined.  When 
from  a  healthy  person  and  freshly  passed,  the  urine  is 
slightly  acidulous.  It  will,  however,  soon  undergo 
change,  and  after  standing  a  number  of  hours  it  usually 
becomes  less  acid,  and  may  even  become  alkaline.  After 
a  meal  the  urine  is  slightly  alkaline,  but  the  reaction  of 
the  mixed  urine  of  twenty-four  hours  is  acid.  Alka- 
linity may  be  the  result  of  taking  the  fixed  alkalies,  of 
an  abnormal  condition  of  the  vesical  mucous  membrane, 
or  of  the  incomplete  emptying  of  the  bladder  due  to 
paralysis,  stricture,  enlarged  prostate,  stone,  morbid 
growth,  foreign  body,  or  other  cause.  If  the  alkalinity 
of  the  urine  is  due  to  carbonate  of  ammonium,  the  pro- 
duct of  the  decomposition  of  urea,  a  gentle  heat  will 
bring  back  the  original  red  tint  of  the  litmus  paper. 
Ammoniacal  urine  may  give  rise  to  cystitis  or  other 
disease  of  the  urinary  organs. 


QUANTITY   OF   URINE.  99 

QUANTITY. 

The  quantity  of  urine  passed  during  twenty-four 
hours,  by  a  healthy  adult  of  150  pounds  weight,  in 
temperate  weather,  and  under  ordinary  circumstances,  is 
between  forty  and  fifty  fluid  ounces. 

The  physiological  as  well  as  the  pathological  condi- 
tions, by  which  the  quantity  and  quality  of  the  urine 
become  affected,  should  engage  the  attention  of  the  ex- 
aminer. A  number  of  things  must  be  kept  in  view, 
such  as  drink,  kind  of  food,  state  of  the  cutaneous  and 
pulmonary  exhalations,  length  of  time  the  urine  is  re- 
tained in  the  bladder,  condition  of  the  stools,  sex,  age, 
sleep,  and  the  influence  of  remedies.  In  order  to 
determine  accurately  the  amount  voided  in  twenty-four 
hours,  it  will  be  necessary  to  resort  to  a  careful  measure- 
ment. If  found  abnormally  small,  inquiry  should  be 
made  whether  the  applicant  has  abstained  from  liquids 
or  whether  abnormal  secretions  have  been  thrown  out 
by  the  skin  or  bowels.  Should  no  adequate  reason 
appear  for  the  deficiency  in  quantity,  the  inevitable 
conclusion  would  be  that  there  is  an  abnormal  state.  It 
may  point  to  simple  congestion  of  the  kidney,  cirrhosis 
of  the  liver,  acute  or  chronic  catarrhal  nephritis,  or 
some  affection  of  the  heart  which  causes  passive  con- 
gestion of  the  renal  veins,  whereby  the  circulation 
through  the  kidneys  is  hindered.  It  only  remains  to 
be  said,  that  an  unusually  small  amount  of  urine,  dis- 
charged regularly,  evidences  some  serious  trouble,  and 
should  cause  the  refusal  of  an  applicant. 

On  the  other  hand,  when  the  quantity  of  urine  in 
twenty-four  hours  is  much  above  the  normal,  without 


100  TEEATISE   ON   MEDICAL   EXAMINATION. 

the  presence  of  any  known  cause,  it  can  be  generally 
inferred  that  the  originating  cause  is  either  diabetes, 
organic  degeneration  of  the  kidneys,  hysteria,  or  some 
other  serious  disease. 


SPECIFIC  GKAVITY. 

The  specific  gravity  should  be  ascertained  by  the  uri- 
nometer.  The  process  consists  in  putting  this  instrument 
into  a  cylindrical  vessel,  filled  with  the  urine  to  be  tested, 
in  which  it  should  freely  float.  The  stem  of  the  instru- 
ment must  not  be  allowed  to  come  in  contact  with  the 
body  or  walls  of  the  cylinder.  In  reading,  the  eye 
must  be  on  a  level  with  the  surface  of  the  fluid,  when 
the  number  corresponding  should  be  noted.  If  the 
solids  are  decreased  the  instrument  will  sink  below  the 
normal  standard;  if  increased,  it  will  rise  above  it.  In 
careful  work  the  specific  gravity  should  be  taken  from 
the  combined  urine  passed  in  twenty-four  hours.  In 
general  the  lower  the  specific  gravity  the  less  the  urea, 
and  this  symptom  is  always  significant.  The  density 
of  the  urine  is  increased  in  the  first  stage  of  acute  fevers, 
in  the  first  stage  of  acute  catarrhal  nephritis,  and  in 
diabetes.  The  specific  gravity  is  decreased  in  diabetes 
insipidus  or  diuresis,  interstitial  nephritis,  and  amyloid 
degeneration. 

An  easy  method  to  obtain  an  approximate  idea  of 
the  amount  of  solids  in  the  urine  is  to  multiply  by  2 
every  degree  of  specific  gravity  above  1000,  which 
will  give  the  number  of  grams  in  1000  c.  c.  of  urine. 
If  a  patient  voids  1000  c.  c.,  or  33£  fluid  drachms  of 
urine  in  twenty- four  hours,  having  a  specific  gravity 


SPECIFIC   GRAVITY   OF   UKINE.  101 

of  1030,  there  would  be  60  grains  or  15  drachms  of 
solids. 

The  density  of  urine  in  health  varies  from  1015  to 
1025,  making  1020  the  average,  while  in  disease  it  is 
likely  to  extend  to  1040  and  even  to  1050,  or  sink  as 
low  as  1005.  In  some  few  instances  these  figures  may 
be  insufficient.  When  the  density  is  high,  there  is  the 
probability  that  the  urine  will  deposit  its  constituents 
before  being  voided,  and  thus  produce  a  variety  of 
troubles  in  the  urinary  passages,  such  as  nephritis, 
cystitis,  hsematuria,  nephralgia,  gravel,  stone  in  the 
bladder,  dysuria,  strangury,  arid  retention  of  urine.  If 
low  in  density,  it  is  largely  increased  in  amount,  either 
by  copious  draughts  of  water  or  some  abnormal  cause, 
as  in  diabetes  insipidus.  Where  the  specific  gravity  is 
abnormally  low — less  than  1015 — some  exhausting 
inflammatory  disease  should  be  suspected.  In  Bright's 
disease,  in  chronic  form,  the  rule  obtains  that,  when  the 
specific  gravity  of  the  urine  is  relatively  lower,  the 
danger  to  life  is  the  greater. 

Where,  however,  the  specific  gravity  is  above  1025, 
particularly  in  a  pale,  limpid  urine,  there  is  every 
reason  to  infer  the  presence  of  sugar.  Any  specific 
gravity  persistently  exceeding  1035  amounts  to  an 
almost  certain  proof  of  the  existence  of  diabetes  mel- 
litus. 


102  TREATISE   ON   MEDICAL   EXAMINATION". 

ABNOBMAL  CONDITIONS  OF  THE  UEINE. 

ALBUMEN. 

Albumen  in  urine  is  frequently  found,  and  very 
many  plans  have  been  suggested  for  its  detection.  The 
question  of  the  presence  of  albumen  necessarily  being 
an  indication  of  organic  disease  of  the  kidneys  should 
be  carefully  considered  by  the  examiner.  We  believe 
that  it  may  often  occur  without  such  organic  disease, 
especially  if  it  be  transient.  It  is  frequently  the  result 
of  congestion  of  the  kidneys,  occurring  in  such  inflam- 
matory diseases  as  measles,  smallpox,  typhoid,  ague, 
diphtheria,  pneumonia,  peritonitis,  rheumatism,  trau- 
matic fever,  etc.  It  may  be  found  wherever  there  is 
obstruction  to  the  free  circulation  of  the  blood,  as  in 
emphysema,  organic  heart  lesions,  abdominal  tumors, 
pregnancy,  cirrhosis  of  the  liver,  etc.  It  may  also 
accompany  an  impoverished  condition  of  the  blood 
and  wasting  of  the  tissues,  as  in  scurvy,  pyaemia,  and 
anaemia. 

It  must  be  remembered  that  pus  or  blood  in  the 
urine  may  account  for  the  presence  of  albumen.  A 
microscopic  examination  will  always  determine  this 
point. 

Should  the  quantity  of  albumen  be  large  and  con- 
stant, with  tube  casts,  renal  epithelium,  or  evidences  of 
fatty  degeneration,  we  may  very  conclusively  affirm  the 
existence  of  organic  disease  of  the  kidneys. 

In  every  case  that  comes  before  the  examiner,  the 
urine  must  be  carefully  tested  for  albumen. 


TESTS   FOR   ALBUMEN.  103 

TESTS  FOE  ALBUMEN. 

Heat  and  Nitric  Acid,  as  a  chemical  test  for  albu- 
men, is  frequently  recommended,  and  is  as  follows : 
Take  a  small  amount  of  the  urine  to  be  tested  (a  fluid 
drachm  will  do);  filter  if  cloudy  ;  if  alkaline,  acidulate 
with  a  drop  or  two  of  acetic  acid.  Be  particular  to 
have  the  specimen  in  a  clean  test  tube,  free  from  every 
trace  of  alkali.  Now  boil.  If  the  liquid  remains  clear, 
there  is  probably  no  albumen.  If,  after  the  addition 
of  a  drop  of  nitric  acid,  the  urine  is  still  unclouded,  it 
may  be  considered  practically  free  from  albumen. 

It  is  possible  to  confound  the  precipitate  from  urates 
or  phosphates  with  albumen.  In  the  case  of  the  urates, 
however,  the  application  of  heat  clears  the  urine,  while 
with  the  phosphates  the  same  result  is  obtained  by  the 
addition  of  nitric  acid.  With  albumen  present,  both 
of  these  agents  only  increase  the  turbidity  of  the 
urine. 

Heller's  Test  is  more  delicate  than  the  preceding, 
and  should  be  used  wherever  there  is  reason  to  suspect 
albumen.  Take  half  a  drachm  to  a  drachm  of  pure, 
colorless  nitric  acid,  and  put  it  in  a  clean,  small  test 
tube.  Incline  the  test  tube  at  an  angle  of  about  45°, 
and  from  a  pipette  allow  to  slowly  trickle  down  the 
side  of  the  tube  an  equal  quantity  of  urine,  rendered 
clear,  if  necessary,  by  filtering.  The  urine  must  dis- 
tinctly overlie  the  acid.  If  albumen  be  present,  there 
will  appear  at  the  junction  of  the  urine  and  acid  a 
white  ring  or  zone,  varying  in  thickness  according  to 
the  amount  of  albumen.  The  ring  caused  by  the  pre- 
cipitation of  urates  is  not  so  sharply  defined  as  that 


104  TREATISE   ON   MEDICAL   EXAMINATION. 

caused  by  albumen,  and  disappears  with  the  application 
of  heat. 

Other  chemical  tests  for  determining  the  existence  of 
alblimen  have  been  suggested,  but  the  two  here  given 
will  suffice  in  most  insurance  examinations. 

Finally,  there  are  some  things  that  should  be  con- 
stantly remembered  in  this  connection,  and  to  these  we 
now  direct  attention. 

1.  In  a  normal  or  healthy  condition  of  the  urine 
there  is  always  entire  absence  of  albumen. 

2.  Healthy  urine,  when  voided  from  the  bladder, 
may  be  acid  or  alkaline. 

3.  Albuminous  urine,  even  when  heavily  charged,  may 
not  show  albumen  on  the  application  of  heat.     It  may 
be  so  excessively  acid,  from  the  presence  of  acetic  or 
hydrochloric  acid,  that  the  acetate  or  hydrochlorate  of 
albumen  is  formed— substances  soluble  in  water  and 
proof  against  coagulation  by  heat.    In  these  cases  nitric 
acid  quickly  detects  the  albumen. 

4.  All  urine  capable  of  furnishing  a  precipitate  of 
albumen  by  heat  will  remain  unchanged  or  have  the 
precipitate  increased  by  the  use  of  a  few  drops  of  nitric 
acid ;  but  the  nitric  acid  will  dissolve  the  precipitate, 
in  case  it  is  not  albuminous  but  composed  of  amorphous 
urates  or  phosphates.     Here  care  should  be  exercised, 
as  in  some  rare  cases  the  addition  of  an  excess  of  nitric 
acid  may  redissolve  the  albuminous  precipitate. 

5.  Sometimes  a  precipitate  cannot  be  effected  in  albu- 
minous urine  by  heat,  if  nitric  acid  is  added  in  excess 
to  the  urine  in  the  test  tube  before  boiling. 

6.  Before  testing  for  albumen,  the  urine,  if  alkaline 
or  neutral,  must  be  acidulated  by  a  few  drops  of  acetic 


SUGAR   IN   URINE.  105 

acid ;  otherwise  there  may  be  no  coagulation  by  heat, 
even  when  highly  charged  with  albumen. 

7.  In  numerous  acute  and  chronic  disorders  albumen 
is  found  to  exist  temporarily,  but  unless  there  is  kidney 
affection,  no  tube  casts  will  likely  appear  under  the 
microscope. 

8.  Where  the  urine  contains  sugar  and  albumen,  it 
will  first  have  to  be  boiled,  then  the  albumen  must  be 
separated  by  filtering,  after  which  the  proper  test  for 
sugar  may  be  made. 

SUGAR 

The  presence  of  sugar  in  the  urine  does  not  always 
indicate  diabetes,  nor  are  the  kidneys  always  diseased 
under  such  circumstances.  They  only  take  up  the 
sugar  in  the  blood  by  the  renal  arteries  and  then  excrete 
it.  Moderate  or  diminutive  amounts  of  sugar  are  fre- 
quently observed  in  the  urine,  the  result  of  some  passing 
influence,  such  as  indulging  in  immoderate  quantities 
of  saccharine  food,  or  the  using  of  chloroform,  ether, 
turpentine,  etc.  In  certain  diseases  there  may  be  traces 
of  sugar  in  the  urine,  as  in  whooping  cough,  asthma, 
epilepsy,  softening  of  the  brain,  abscesses  and  tumors  of 
the  cerebellum,  affections  of  the  nerves ;  also  in  intense 
grief,  sudden  mental  shocks,  blows  in  the  epigastrium, 
disordered  digestion,  hepatic  disease,  exposure  to  cold, 
uterine  troubles,  and  hereditary  influences.  All  or  any 
of  these  may  have  a  tendency  to  produce  sugar  in  the 
urine  without  indicating  genuine  diabetes.  But  where 
a  palpable  or  important  departure  from  health,  without 
any  assignable  cause,  becomes  apparent,  the  urine  at  the 
same  time  being  freely  charged  with  sugar  and  voided 
8 


106  TREATISE   ON    MEDICAL   EXAMINATION. 

in  unusual  quantity,  and  where  these  conditions  are 
attended  with  great  thirst,  voracious  appetite,  and  a  dry 
and  harsh  skin,  the  examiner  can  fairly  infer  the  pres- 
ence of  diabetes. 

Again,  if  these  symptoms  are  not  well  developed,  and 
yet,  after  repeated  examinations,  the  persistent  existence 
of  sugar  in  the  urine  is  shown,  together  with  an  increased 
amount  of  urine  discharged,  there  can  be  no  doubt  that 
diabetes  exists.  The  need  of  great  care  will  be  recog- 
nized from  these  statements.  Diabetes  is  a  formidable 
disease,  and  its  existence  must  be  determined  largely  by 
the  presence  of  sugar  in  the  urine. 

The  characteristics  of  diabetic  urine  are  the  abund- 
ance of  urine,  its  singular  color  (pale,  or  faintly  yellow- 
ish with  a  tinge  of  green),  its  transparency,  its  producing 
no  sediment  on  standing,  and  its  specific  gravity,  ranging 
from  1030  to  1040,  and  even  at  times  to  1050  and  up- 
ward. 

TESTS  FOR  SUGAE. 

A  number  of  tests  might  be  given  were  this  at  all 
necessary.  We  shall  select,  however,  those  that  are 
most  convenient  in  application  and  at  the  same  time 
satisfactory  in  their  results. 

Trommer's  Test. — Place  a  small  quantity  of  the 
suspected  urine  in  a  test  tube  and  add  a  few  drops  of 
a  weak  solution  of  sulphate  of  copper,  till  the  urine  is 
colored  by  the  copper.  Then  add  an  equal  bulk  of 
liquor  potassa  and  boil.  If  sugar  be  present,  a  reddish- 
yellow  precipitate  of  the  sub-oxide  of  copper  is  thrown 
down.  Care  must  be  taken  not  to  mistake  the  trans- 
parent or  greenish  precipitate  of  earthy  phosphates  for 


BLOOD    IN    URINE. 


107 


sugar.  A  simple  change  of  color  is  not  sufficient  evi- 
dence, but  there  must  be  an  actual  precipitate  of  the 
character  described. 

If  albumen  be  found,  it  must  be  coagulated  and  re- 
moved by  filtering  before  the  urine  is  tested  for  sugar. 

The  Bismuth  Test  may  be  used  to  confirm  the 
result  of  the  copper  test.  To  about  a  drachm  of  urine 
add  an  equal  amount  of  liquor  potassse,  and  then  about 
two  grains  of  subnitrate  of  bismuth.  Now  boil  for  a 
couple  of  minutes,  and  if  sugar  be  present,  the  bismuth 
will  be  changed  to  some  shade  between  gray  and  black, 
according  to  the  amount  of  sugar  contained  in  the  urine. 
In  this  test,  also,  albumen,  if  found,  must  be  removed 
before  testihg  for  sugar. 


BLOOD. 

Blood  in  the  urine  is  sometimes  observed  in  small  or 
large  quantity.  It  imparts  a  reddish  or  smoky  appear- 
ance, the  sediment  assuming  a  brownish  hue,  like  coffee 
grounds.  Diminutive  coagula  may  be  recognized  at  the 
bottom  of  the  test  tube.  The  proper  test  is  sulphuric 
acid,  which  changes  the  color  of  the  urine  to  a  reddish- 
brown,  thereby  revealing  the  existence  of  hsematin.  The 
appearance  of  blood  corpuscles  under  the  microscope  is 
so  well  known  to  the  physician  that  a  description  seems 
unnecessary.  It  is  highly  important  to  ascertain  the 
cause  whenever  blood  appears.  It  may  result  from 
injuries,  calculi,  pyelitis,  Bright's  disease,  tumor  of  the 
bladder,  cystitis,  active  hypersemia,  or  nephritis,  also  in 
the  course  of  purpura,  scarlet  and  typhus  fever,  malaria, 
cholera,  etc. 


108  TREATISE   ON   MEDICAL   EXAMINATION. 

However  produced,  no  one  in  this  condition  will  be 
judged  competent  for  life  insurance  until  the  urine 
has  resumed  a  normal  state. 


BILE. 

Bile  in  the  urine  may  be  due  to  hepatic  disorder  or 
to  obstruction  of  the  biliary  ducts.  When  persistently 
present  jaundice  always  coexists.  The  urine  is  very 
dark. 

The  simplest  test  for  bile  pigment  is  to  place  on  a 
clean  white  plate  a  few  drops  of  the  urine,  and  by  the 
gide  of  this  a  few  drops  of  nitric  acid.  By  tilting  the 
plate,  the  liquids  may  be  made  to  unite,  when  a  play  of 
colors  will  be  observed,  commencing  with  green  and 
blue,  and  passing  to  violet  and  red,  perhaps  even  to 
yellow  and  brown. 

MUCUS. 

Mucus  invariably  exists  in  small  amount  in  the 
urine.  Occasionally  the  quantity  is  so  minute  as  to 
escape  observation  until  precipitated  by  acetic  acid.  If 
iodine  is  added  to  acetic  acid  in  the  urine,  the  mucus 
is  both  precipitated  and  colored,  and  the  epithelial  cells 
thereby  rendered  more  definable  and  distinct.  Should, 
at  any  time,  any  part  of  the  urinary  tract  become 
irritated,  the  mucus  will  speedily  increase  in  quantity, 
and  should  inflammation  ensue,  pus  will  enter  the 
urine,  and  traces  of  albumen  consequently  appear. 
Thus  mucus  will  be  caused  by  irritation,  while  pus  and 
albumen  will  characterize  inflammation. 


UKEA   IN    TJKINE. 

PUS. 


109 


Pus  in  the  urine  produces  a  whitish,  milky  appear- 
ance, and,  after  settling,  a  dense,  yellowish  white  sedi- 
ment. The  urine  readily  becomes  alkaline,  if  not 
already  so  when  voided,  and  will  contain  more  or  less 
albumen,  generally  in  proportion  to  the  amount  of  pus 
present.  Now,  if  the  urine  is  found  acid  when  recently 
passed,  it  is  supposed  that  the  pus  has  its  origin  in  the 
kidneys,  while,  if  found  alkaline  or  becoming  alkaline 
soon  after  being  voided,  the  pus  is  presumably  from 
the  bladder.  Pus  in  the  urine  may  proceed  from 
abscesses  along  the  mucous  membrane  of  the  urinary 
canal  or  from  gonorrhoea,  gleet,  or  leucorrhoea.  Of 
course,  the  significance  is  greater  if  the  pus  is  of  cystic 
or  renal  origin.  To  determine  whether  the  bladder  or 
kidneys  are  involved,  the  history  of  the  case  and  all 
symptoms  present  must  be  carefully  considered.  The 
test  for  pus  is  by  liquor  potassse.  Allow  the  urine  to 
settle,  pour  off  the  supernatant  liquid,  and  add  liquor 
potassse.  The  pus  is  converted  into  a  viscid,  gelatinous 
substance,  adhering  closely  to  the  bottle  or  test  tube. 
By  placing  some  of  the  suspected  urine  under  the 
microscope,  the  pus  corpuscles  may  be  readily  found. 


UEEA.     . 

Urea  is  always  found  in  some  quantity  in  normal 
urine,  being  excreted  by  the  kidneys  from  the  blood, 
in  which  it  is  a  constant  ingredient.  It  is  produced 
mainly  by  the  disintegration  of  tissue,  and  hence 
becomes  a  most  important  indication  of  the  wear  and 


110  TREATISE   ON    MEDICAL   EXAMINATION. 

tear  of  the  system.  Its  amount  varies  with  physical  or 
mental  exertion,  or  with  the  ingestion  of  nitrogenized 
food.  It  is  present  in  abnormal  quantity  in  all 
acute  'febrile  diseases,  in  inflammatory  conditions,  in 
pyaemia,  and  in  nervous  affections.  It  is  diminished  in 
some  forms  of  Bright's  disease,  in  long-continued 
organic  affections,  and  before  paroxysms  of  gout  or 
asthma.  If,  owing  to  organic  kidney  disease,  the  urea 
is  not  properly  eliminated,  it  accumulates  in  the  blood 
and,  acting  as  a  poison,  produces  the  train  of  symptoms 
comprised  under  the  term  urcemia.  The  examiner 
should  investigate  as  to  the  amount  of  urea,  and  should 
not  estimate  too  lightly  its  excess  or  deficiency. 

URIC  ACID. 

-\ 

Uric  acid  in  combination  with  potassium,  sodium, 
and  ammonium,  is  also  one  of  the  normal  constituents 
of  urine.  When  freed  from  its  bases  it  is  immediately 
precipitated,  as  it  is  very  insoluble.  Urea  is  considered 
to  be  uric  acid  oxidized  to  a  greater  degree  ;  conse- 
quently uric  acid  is  derived  from  the  same  sources  and 
varies  under  the  same  conditions  as  urea.  Like  urea, 
it  is  increased  in  the  fevers,  acute  rheumatism,  gout, 
and  in  functional  or  organic  gastric  and  hepatic  dis- 
orders ;  while  it  is  decreased  in  advanced  Bright's 
disease,  diabetes,  anaemia,  chlorosis,  hysteria,  etc.  The 
variation  in  the  amount  of  uric  acid  eliminated  is  not 
of  such  great  importance  as  the  place  and  time  of  its 
precipitation.  Normal  urine  may  at  the  end  of  twenty 
to  twenty-four  hours  contain  a  deposit  of  uric  acid 
crystals,  easily  recognized  by  the  microscope.  When, 


OXALATE   OF    LIME   IN   URINE.  Ill 

however,  the  deposit  is  detected  within  three  or  four 
hours  after  the  urine  has  been  passed,  it  indicates  that 
the  urine  is  of  such  character  as  to  allow  the  precipi- 
tation of  uric  acid  in  some  parts  of  the  urinary  passages, 
thus  showing  a  tendency  to  the  formation  of  gravel  or 
stone.  Such  conditions  should  reject  the  applicant. 

UEATES. 

Urates  are  produced  by  a  combination  of  uric  acid 
with  an  alkaline  base,  such  as  sodium,  potassium,  am- 
monium, calcium,  and  magnesium.  The  most  frequent 
forms  are  the  urates  of  sodium  and  ammonium. 
Urates  are  soluble  in  urine  at  the  temperature  of 
the  body ;  but  as  the  urine  cools  they  are  apt  to.  be 
precipitated  (especially  the  acid  urates)  in  crystal- 
line form  or  in  amorphous  powder.  The  color  of  the 
deposit  may  be  pink,  brown,  or  white.  The  continued 
presence  in  the  urine  of  a  considerable  deposit  of  urates 
should  always  put  the  examiner  on  his  guard,  as  this 
condition  is  often  dependent  upon  serious  disease  of 
important  organs.  We  would  say  that  a  concentrated 
urine,  of  persistently  high  specific  gravity,  and  loaded 
with  urates,  should  reject  the  applicant,  aside  from  all 
other  considerations. 

OXALATE  OF  LIME.  . 

The  occasional  occurrence  in  the  urine  of  a  few  crys- 
.tals  of  oxalate  of  lime  is  without  significance.  This 
substance  may  be  found  after  articles  containing  oxalic 
acid,  such  as  rhubarb  and  tomatoes,  have  been  eaten. 


112  TREATISE   ON   MEDICAL   EXAMINATION. 

Wherever  persistent  and  in  any  quantity,  however,  it 
must  be  regarded  as  indicating  a  diseased  condition. 
Under  such  circumstances  the  possibility  of  calculus  of 
this  variety  must  be  considered. 

PHOSPHOEIC  ACID. 

Phosphoric  acid  is  seemingly  an  important  factor  in 
the  human  economy,  for  it  is  found  in  the  blood,  bones, 
nerves,  and  muscles.  As  an  ingredient  in  the  urine, 
the  amount  eliminated  is  greatly  affected  by  disease. 
We  find  it  to  be  abnormally  increased  in  all  inflam- 
matory diseases  of  the  nervous  system  and  disease  of  the 
bones,  as  in  paralysis,  acute  mania,  delirium  tremens, 
and  rickets.  It  is  generally  diminished  in  pneumonia, 
Bright's  disease,  gout,  and  rheumatism. 

The  phosphoric  acid  in  the  urine  is  found  in  combi- 
nation with  calcium,  magnesium,  and  sodium.  Of  these 
the  first  two,  known  as  the  earthy  phosphates,  are  soluble 
in  an  acid  urine,  but  are  speedily  precipitated  when  the 
urine  becomes  alkaline ;  while  the  last,  or  alkaline 
phosphate,  is  soluble  in  water,  and  is  not  precipitated 
by  the  addition  of  alkalies. 

With  phosphates,  also,  the  possible  danger  of  cal- 
culus is  to  be  considered. 

LEUCIN  AND  TYEOSIK. 

These  substances  will  hardly  be  found  by  the  insur- 
ance examiner.  They  are  for  the  most  part  dependent 
on  grave  hepatic  disease,  as,  for  instance,  acute  yellow 
atrophy  and  phosphorus  poisoning. 


TUBE   CASTS.  113 


Leucin  closely  resembles  oil  globules.  It  does  not 
refract  light  quite  so  strongly,  however,  as  oil,  and, 
properly  illuminated,  will  present  a  somewhat  striated 
appearance. 

Tyrosin  occurs  in  the  form  of  fine  needles  grouped 
in  sheaf-like  bundles. 

MICROSCOPIC  EXAMINATION  OF  URINE. 

The  urine  to  be  examined  should  be  well  shaken, 
poured  into  a  clean  conical  glass,  covered,  and  allowed  to 
settle  for  twelve  hours  or  more.  A  small  quantity 
should  then  be  taken,  by  a  pointed  glass  pipette,  from 
the  bottom  of  the  glass,  and  a  drop  deposited  upon  the 
glass  slide.  Cover  with  a  thin  glass  cover,  remove  the 
superfluous  fluid,  and  examine  with  a  i  in.  or  £  in. 
objective.  Observe  the  various  crystals  and  the  amor- 
phous urates  and  phosphates  ;  also  epithelial  cells,  oil 
globules,  and  pus,  mucus,  or  blood  corpuscles.  Then 
examine  the  field  with  the  greatest  care  for  tube  casts. 

TUBE  CASTS. 

The  examination  of  one  slide  is  not  sufficient  to 
determine  the  absence  of  tube  casts.  Three  or  four 
should  be  taken  and  perseveringly  searched,  espe- 
cially if  albumen  be  present  in  the  urine.  As  a  rule, 
albumen  and  casts  go  together.  Tube  casts  may  be 
classified  as  hyaline,  waxy,  epithelial,  blood,  granular, 
and  fatty  casts. 

Hyaline  Casts  are  transparent  cylinders,  produced 
by  the  exudation  of  an  albuminous  substance  into  the 


114  TREATISE   ON    MEDICAL   EXAMINATION. 

uriniferous  tubules  from  the  surrounding  capillaries. 
This  substance  coagulates,  contracts,  is  washed  into  the 
pelvis  of  the  kidney  by  the  secretion  of  urine  behind 
it,  and  so  escapes  from  the  body.  The  diameter  of  the 
hyaline  cast  depends  upon  the  presence  or  absence  of 
an  epithelial  lining  in  the  tubule  in  which  it  is  formed. 
This  cast  may  be  met  with  in  chronic  paren^chymatous 
and  chronic  interstitial  nephritis,  and  sometimes  in  the 
acute  desquamative  form.  Occasionally  it  may  be  found 
in  acute  hypersemia. 

Waxy  Casts  closely  resemble  the  hyaline.  They 
have,  however,  a  more  solid  appearance  and  seem 
slightly  darker  than  the  hyaline  casts.  They  are 
highly  refractive  and  are  sometimes  notched.  They 
always  indicate  chronic  nephritis,  usually  the  paren- 
chymatous  variety,  and  hence  are  always  to  be  re- 
garded as  evidence  of  serious  lesions. 

Epithelial  Casts  are  supposed  to  be  produced  by 
the  entanglement  in  the  albuminous  exudate  of  de- 
tached epithelial  cells.  They  indicate  an  acute 
nephritis. 

Blood  Casts  are  formed  in  the  same  manner  as  the 
preceding,  by  the  entanglement  of  blood  cells  present 
in  the  uriniferous  tubules.  Like  epithelial  casts,  blood 
casts  indicate  an  acute  nephritis. 

Granular  Casts  contain  granular  matter  derived 
from  broken  down  epithelium  or  blood  cells.  They 
are  found  in  chronic  parenchymatous  and  chronic 
interstitial  nephritis,  and  indicate  long-existing  organic 
disease. 

Fatty  Casts  contain  oil  globules,  either  free  or 
within  epithelial  cells.  They  are  only  found  in  far- 


EPITHELIAL    CELLS.  115 

advanced  disease  of  the  kidney,  and  prove  that  fatty 
degeneration  has  taken  place. 

If  tube  casts  are  discovered,  the  examiner  will 
naturally  infer  that  the  kidneys  are  diseased  in  some 
form.  This  discovery  would  not  demonstrate  the 
existence  of  a  permanent  organic  disease,  for  tube  casts 
are  often  found  with  albuminous  urine  in  acute  diseases. 
However,  should  such  symptoms  develop  as  are  gen- 
erally found  in  B  right's  disease,  and  the  urine,  for  weeks, 
be  albuminous  with  tube  casts  constantly  present,  the 
examiner  can  then  positively  affirm  the  presence,  in 
some  form,  of  organic  disease  of  the  kidney.  The 
examiner  may  sometimes  find  epithelial  cells  from  the 
uriniferous  tubules  and  blood  corpuscles,  but  such 
results  generally  imply  congestion  of  the  kidneys 
without  any  special  disease. 

EPITHELIAL  CELLS. 

Epithelial  cells  from  different  portions  of  the  genito- 
urinary tract  may  bear  so  close  a  resemblance  to  each 
other  that  the  exact  location  of  the  source  from  which 
they  come  may  be  impossible.  A  few  points,  however, 
may  be  given.  Squamous  epithelium  is  derived  from 
the  superficial  layer  of  the  bladder,  or,  in  females,  from 
the  vagina.  The  vaginal  cells  are  usually  larger  and 
flatter  than  those  from  the  bladder.  This  variety  of 
epithelium  is  more  or  less  polygonal  in  shape.  A  great 
increase  in  the  amount  of  squamous  epithelium  together 
with  pus  in  the  urine  may  point  to  cystitis,  leucorrhoea, 
or  specific  vaginitis.  Round  epithelial  cells  are  found  in 
certain  parts  of  the  uriniferous  tubules,  and  in  the  deep 


116  TREATISE   ON    MEDICAL    EXAMINATION. 

layers  from  the  pelvis  of  the  kidney,  bladder,  and  male 
urethra.  In  the  straight  portions  of  the  uriniferous 
tubules  the  epithelium  is  of  a  cubical  variety.  Columnar 
epithelium  may  be  from  the  superficial  layers  of  the 
pelvis  of  the  kidney,  from  the  ureters,  or  from  the 
urethra. 

In  an  alkaline  urine  the  epithelial  cells  are  gradually 
destroyed. 

THE  GENITO-URINABY  OKGANS. 

Within  a  comparatively  recent  period  diseases  of  the 
genito-urinary  organs  have  developed  into  increased 
importance  on  account  of  numerous  additions  to  our 
knowledge.  Abnormal  deviations  in  the  urine  have 
always  been  indicative  of  morbid  conditions  of  the 
kidneys  and  blood.  By  the  improvements  wrought  by 
frequent  experiment  and  higher  skill,  we  have  not  only 
learned  to  discern  new  features  in  disease — and  now 
and  then  a  disease  reputed  to  be  new — but  also  adopted 
improved  and  more  successful  methods  of  treatment. 

The  urine  often  plainly  reveals  not  only  the  weak- 
nesses and  diseases  that  belong  to  its  concealed  organs, 
but  the  dangerous  defects  that  underlie  the  constitution 
and  threaten  the  tenure  of  life.  In  view  of  these  facts, 
we  think  it  proper  to  direct  the  thoughtful  attention  of 
the  examiner  for  insurance  to  the  subjects  here  follow- 
ing:— 

THE  KIDNEYS. 

The  kidneys  are  more  susceptible  to  injury  than  is 
usually  believed.  When  diseased  they  readily  increase 
or  diminish  in  size,  conditions  that  may  be  largely 


FOLYURIA.  117 

determined  by  physical  examination.  Enlargement 
frequently  proceeds  from  calculi,  nephritis,  cancerous 
and  tubercular  deposits,  hydatid  cysts,  and  simple  dis- 
tention.  This  last  condition  is  mostly  the  result  of  an 
obstruction  of  the  ureters.  A  tumor  is  also  occasionally 
developed  at  the  upper  edge  or  border  of  a  kidney  from 
disease  of  the  suprarenal  capsule.  It  has  been  very 
properly  recommended,  in. the  examination  of  the  kid- 
neys, that  the  applicant  be  placed  flat  on  his  face,  or  rest 
on  his  hands  and  feet.  The  size  of  the  organ  should 
then  be  determined  by  the  examiner.  This  is  done  by 
pressure  with  the  fingers  in  the  lumbar  region,  and  by 
percussion.  If  enlargement  is  manifested  it  should  be 
critically  examined,  for  it  may  be  of  the  kidney  itself 
or  may  indicate  the  presence  of  a  tumor.  In  either 
case,  if  there  is  palpable  enlargement  of  one  or  both 
kidneys,  or  if  there  is  discernible  any  hypertrophy, 
cyst,  or  growth  in  the  lumbar  region,  every  applicant 
for  insurance  must  be  declined,  regardless  of  cause. 

POLYUEIA. 

Polyuria  is  also  known  as  diabetes  insipidus  and 
diuresis. 

It  is  a  persistent  discharge  of  a  large  quantity  of  clear, 
transparent  urine  of  low  specific  gravity,  containing 
neither  albumen  nor  sugar. 

The  causes  are  usually  nervous,  as  from  shock,  nervous 
strain,  blows  to  the  head,  tubercular  and  simple  cerebro- 
spinal  meningitis,  cranial  tumors  (especially  of  the 
cerebellum  or  medulla),  disease  of  the  solar  plexus, 


TREATISE   ON    MEDICAL   EXAMINATION. 

or  great  splanchnic  nerves,  mental  excitement,  hysteria, 
insolation,  and  tobacco.  A  strong  predisposing  cause 
is  heredity. 

As  symptoms  of  the  affection,  we  have  intense  thirst, 
frequent  micturition,  increased  quantity  of  urine,  rang- 
ing from  seven  to  forty  pints  in  the  twenty-four  hours, 
loss  of  flesh  and  strength.  When  congenital,  it  is  at 
times  incurable ;  also  when  dependent  upon  organic 
changes  in  nervous  system.  In  other  conditions  cases 
are  frequently  relieved ;  but  applicants  affected  with  this 
disease  are  not  to  be  accepted  until  cured. 

ALBUMINURIA. 

This  simply  implies  albumen  in  the  urine,  and  is  not 
a  separate  and  distinct  disease,  but  rather  a  symptom  of 
disease. 

This  affection  may  be  due:  1st,  to  blood  changes,  as 
in  the  periodical  and  eruptive  fevers,  also  in  puerperal 
fever,  diphtheria,  gout  and  rheumatism,  etc. ;  2d,  to 
obstructions  in  the  renal  circulation,  as  in  pneumonia, 
emphysema,  gravid  uterus,  abdominal  tumor,  obstruc- 
tive valvular  heart  disease,  weak  heart,  and  disease  of 
kidneys ;  3d,  to  certain  poisons,  as  alcohol,  lead,  mer- 
cury, iodide  of  potassium,  cantharides,  arsenic,  chlorate 
of  potassium,  etc.  Whenever  pus  or  blood  is  present  in 
considerable  amount  in  urine,  such  constituents  would 
be  sufficient  to  account  for  a  small  bulk  of  albumen. 

The  discovery  of  albumen  in  the  urine  should  reject 
the  applicant.  At  least  until  re-examinations  prove  it 
to  be  no  longer  present. 


BKIGHT'S  DISEASE  OF  THE  KIDNEYS.          119 
CHRONIC  CONGESTION  OF  THE  KIDNEYS. 

This  may  be  either  irritative  or  passive.  As  an 
example  of  the  former,  may  be  mentioned  lithiasis, 
where  there  is  a  great  excess  of  uric  acid  and  urates  to 
be  excreted  by  the  kidneys.  Alcohol  in  excess,  certain 
articles  of  food,  certain  drugs,  also  malaria  act  as  causes 
of  irritative  chronic  congestion  of  the  kidneys. 

Passive  chronic  congestion  of  the  kidney  is  usually 
due  to  a  mechanical  cause,  and  is  typically  met  with  in 
valvular  disease  of  the  heart  or  in  fatty  degeneration 
of  that  organ.  This  is  known  as  the  cardiac  or  cyanotic 
kidney,  advanced  stages  of  which  are  spoken  of  as 
cardiac  induration. 

The  urine  is  variable,  usually  scanty,  high  colored, 
throwing  down  a  considerable  sediment  composed  of 
urates  and  phosphates  with  excess  of  coloring  matter. 
Albuminuria  is  also  present,  but  tube  casts  are  absent. 
Acute  catarrhal  nephritis  is  particularly  apt  to  be 
developed.  Any  applicant  with  a  tendency  to  chronic 
congestion  of  the  kidney  must  be  declined. 

BRIGHT'S  DISEASE  OF  THE  KIDNEYS 

Is  now  frequently  brought  into  notice,  and  is  a  most 
serious  disease.  This  fact  should  stimulate  the  examiner 
to  a  searching  investigation  of  the  renal  organs  in  every 
case  before  recommending  the  risk.  The  symptoms 
pointing  to  this  disease  are  frequently  slow  and  insidious 
in  their  development.  The  applicant  may  not,  in  many 
cases,  be  conscious  of  any  disease  or  ailment  whatever. 
Therefore,  the  essential  points,  by  which  the  presence 


120  TREATISE   ON    MEDICAL    EXAMINATION. 

of  the  disease  is  recognized,  and  through  which  the 
tendency  to  it  is  seen,  should  be  carefully  and 
thoroughly  investigated.  A  convenient  method  of 
investigation,  arranged  to  accomplish  this  purpose,  is 
the  following: — 

1.  Is  the  skin  usually  harsh  and  dry  ? 

2.  Is  there  anaemia  or  pallor  of  countenance? 

3.  Is  there  complaint  of  weakness  and  want  of  energy? 

4.  Is  there  a  dropsical  state  or  cedema  around  the 
eyes  and  in  the  lower  extremities  ? 

5.  Is  there  frequent  headache,  misty  vision,  spots 
before  the  eyes,  or  noises  in  the  ears? 

6.  Is  there  dyspepsia,  nausea  or  vomiting  ? 

7.  Are  the  bowels  in  an  irritable  condition  ? 

8.  Are  there  symptoms  indicative  of  disease  of  the 
liver  ? 

9.  Is  there  any  disease  of  the  heart,  such  as  hyper- 
trophy or  valvular  insufficiency  ? 

10.  Is  there  any  indication  of  consumptive  taint  ? 

11.  Has  there  been  any  pneumonia,  pleurisy,  or  in- 
flammation of  the  heart  ? 

12.  Is  there  any  chronic  bronchitis  or  rheumatism  ? 

13.  Has  there  been  syphilis  at  any  time  ? 

14.  Is  there  more  or  less  of  intemperance  or  free 
living  ? 

15.  Does  occupation  expose  to  cold  and  wet? 

16.  Is  the  climate  humid,  marshy,  or  on  the  sea- 
coast  ? 

17.  Is  the  urine  scanty  or  free  during  the  twenty- 
four  hours  ? 

18.  Is  it  albuminous;  if  so,  to  what  extent?     Is  the 
albumen  persistent  or  transitory  ? 


ACUTE  BRIGHT'S  DISEASE.  121 

19.  Is  there  any  deficiency  of  urea  in  the  urine  ? 

20.  Is  the  urine  clear,  smoky,  or  dark  ? 

21.  Is  the  specific  gravity  normal? 

22.  Has  it  any  traces  of  sugar  or  pus  ? 

23.  Does  blowing  into  it  have  a  tendency  to  produce 
bubbles  ? 

24.  Does  the  microscope  show  any  epithelial  cells, 
granules,  fat  or  tube-casts  ? 

25.  Does  the  ophthalmoscope  show  the  presence  of 
minute,  white  exudations  on  the  retina  of  the  eye  ? 

In  reference  to  the  last  question,  we  observe  that  the 
exudations  referred  to  consist  in  the  grouping  of  minute 
circular  spots,  of  a  pearly  white  color,  which  stand  out 
from  the  retina  in  a  marked  degree.  Bright's  disease 
is  most  frequently  developed  between  the  ages  of  thirty 
and  fifty  years.  Males  are  more  liable  than  females. 

The  term  "  Bright's  Disease  "  is  a  general  one,  in- 
cluding tne  various  forms  of  nephritis.  To  a  more 
careful  consideration  of  these  various  forms  we  would 
now  direct  attention. 

ACUTE  BRIGHT'S  DISEASE. 

Synonyms  : — Acute  desquamative  nephritis,  acute 
tubal  nephritis,  acute  renal  dropsy.  This  form  of 
kidney  disease  will  hardly  come  to  the  notice  of  the 
examiner.  Following  exposure  or  scarlet  fever,  the 
symptoms  are  acute.  We  find  febrile  disturbance, 
extensive  dropsy  first  manifested  in  the  eyelids  or  in 
the  feet,  dull  pain  in  the  region  of  the  kidneys,  vesical 
irritability,  with  a  urine  usually  scanty,  high  colored, 
of  high  specific  gravity,  and  containing  a  large  amount 
9 


122  TREATISE    ON    MEDICAL    EXAMINATION. 

of  albumen  together  with  blood,  blood  or  epithelial 
casts,  and  in  some  cases  hyaline  casts.  Of  course,  if 
such  conditions  should  be  detected,  rejection  must 
follow. 


CHRONIC  PARENCHYMATOUS  NEPHRITIS. 

Synonyms  : — Chronic  non-desquamative  nephritis, 
chronic  tubal  nephritis,  large  white  kidney,  This  is  a 
disease  frequently  met  with  and  consists  in  a  chronic 
inflammation  of  the  mucous  membrane  lining  the 
uriniferous  tubules.  This  disease  commonly  occurs 
following  an  attack  of  acute  inflammation,  but  its 
approach  may  be  insidious.  The  subjects  of  this  form 
of  nephritis  are  usually  under  forty  years  of  age. 

The  early  symptoms  are  not  diagnostic.  Usually  we 
find  loss  of  flesh  and  strength,  capricious  appetite,  and 
digestion  impaired.  After  some  time  we  have  in- 
creased frequency  of  micturition,  particularly  noticeable 
at  night,  anemia,  sense  of  weight  and  fullness  in  renal 
region,  slight  pufliness  about  the  eyes  in  the  morning 
and  about  the  feet  at  night.  This  swelling  or  oedema 
may  extend  over  the  face  and  up  the  extremities. 
Dyspnoea  to  greater  or  less  degree  is  apt  to  be  present, 
also  effusions  into  the  cavities  lined  by  serous  mem- 
branes. The  urine  is  usually  diminished  in  quantity, 
though  in  many  cases  the  amount  is  unchanged.  It 
always  shows  considerable  albumen.  The  specific 
gravity  is  usually  a  little  above  normal.  Granular 
epithelial  casts  predominate,  though  hyaline  or  fatty 
casts  are  also  found.  Here,  as  in  all  other  forms  of 
nephritis,  no  application  can  be  accepted. 


CHRONIC    INTERSTITIAL   NEPHRITIS.  123 

CHRONIC  INTERSTITIAL  NEPHRITIS. 

Synonyms  : — Contracted  kidney,  small  granular  kid- 
ney, gouty  kidney,  renal  cirrhosis,  renal  sclerosis.  In 
this  form  of  nephritis  the  inflammation  is  mainly 
confined  to  the  connective  tissue,  and  the  condition 
resulting  is  very  similar  to  that  found  in  cirrhosis  of 
the  liver.  The  subjects  of  interstitial  nephritis  are 
usually  from  forty  to  sixty  years  of  age.  Among  the 
causes  we  may  mention  alcoholism,  gout,  lead  poison- 
ing, malaria,  long  continued  mental  strain,  and  syphilis. 
The  development  of  the  disease  may  be  exceedingly 
slow,  and  the  applicant  totally  unconscious  of  any 
trouble. 

As  earlier  symptoms  we  find  an  anaemic  or  pallid 
countenance,  loss  of  strength,  disorders  of  digestion, 
headache,  and  increased  frequency  of  micturition. 
Dropsy,  if  present  at  all,  is  very  moderate  until  late 
in  the  disease.  Bleeding  from  nose  or  bowels  occurs ; 
also  a  form  of  albuminous  retinitis.  The  arterial 
tension  is  high  and  the  left  ventricle  of  the  heart  is 
usually  hypertrophied.  •  Ursemic  symptoms,  coma  and 
convulsions,  are  more  likely  to  occur  here,  than  in 
the  other  forms  of  nephritis.  The  urine  is  increased 
in  quantity  and  of  low  specific  gravity,  rarely  above 
1010.  Albumen  is  in  small  amount  and  may  some- 
times be  absent  from  the  urine  for  days  at  a  time. 
The  urea  excreted  in  the  twenty-four  hours  is  not 
decreased  till  late  in  the  disease.  Tube  casts  are  by  no 
means  so  abundant  as  in  the  preceding  form.  Those 
found  are  hyaline  or  granular. 

Chronic  interstitial  nephritis  should  always  be  promi- 


124  TREATISE   ON   MEDICAL   EXAMINATION. 

nently  before  the  mind  of  the  examiner,  for,  unless  the 
greatest  care  be  exercised,  the  existence  of  this  disease 
is  very  apt  to  be  overlooked. 

AMYLOID   DEGENEKATION   OF  THE 
KIDNEY. 

Synonyms : — Waxy,  lardaceous,  or  albuminoid  de- 
generation of  the  kidney.  In  this  disease  we  have  a 
peculiar  starch-like  degeneration  beginning  in  the  walls 
of  the  arterioles  and  extending  to  the  connective  tissue 
and  to  the  basement  membrane  of  the  tubules. 

It  may  follow  syphilis,  tuberculosis,  long  continued 
suppuration,  or  caries.  It  most  frequently  occurs  be- 
tween the  ages  of  twenty  and  thirty. 

The  progress  of  the  disease  is  slow.  The  face  ex- 
hibits a  peculiar  cachectic  appearance.  Dropsy  is 
slight  or  absent.  There  is  usually  marked  emaciation. 
The  liver  and  spleen  are  enlarged  and  present  evidence 
of  similar  degeneration.  Hemorrhages  and  cardiac 
hypertrophy  are  wanting.  Diarrhoea,  depending  on 
change  in  the  intestinal  vessel?,  exists.  There  is  also 
marked  thirst.  The  urine  is  increased  in  quantity  and 
of  low  specific  gravity,  1010  to  1015.  It  contains 
albumen  in  considerable  amount.  Tube  casts  are  few 
in  number,  and  when  found  are  pale  and  transparent. 

The  points  given  will,  we  think,  be  sufficient  to 
distinguish  amyloid  degeneration  from  the  preceding 
forms  of  nephritis.  We  shall  now  turn  from  Bright's 
Disease  to 


PYELITIS.  125 

CANCER  OF  THE  KIDNEY. 

This  is  a.  very  rare  affection.  Primary  cancer  of 
the  kidney  is  usually  encephaloid  and  occurs  chiefly  in 
male  children  before  puberty. 

Secondary  cancer  usually  occurs  in  adults  and  gives 
rise  to  pains  in  thighs  and  near  the  spine,  especially  on 
right  side,  enlarged  superficial  veins,  oadema  of  the 
feet,  cachexia,  emaciation,  hsematuria,  which  is  not 
profuse,  and  a  renal  tumor  discoverable  by  palpation 
and  percussion.  This  disease  is  extremely  fatal,  its 
duration  being  only  from  one  to  three  years. 


TUBERCULOSIS -OF  THE  KIDNEY. 


This  is  another  rare  disease,  usually  secondary, 
occurring  between  twenty  and  forty,  and  giving 
symptoms  resembling  pyelitis,  such  as  dull  pain  in  the 
renal  region,  frequent  urination,  albuminous  urine 
that  is  turbid  and  contains  a  small  amount  of  blood, 
pus,  or  epithelium  and  occasionally  fragments  of  broken 
down  tubercles.  The  left  kidney  is  usually  selected, 
and  in  almost  half  tbtf  cases  a  renal  tumor  can  be 
detected  after  careful  physical  examination. 

The  diagnostic  symptoms  are  pulmonary  tubercu- 
losis, portions  of  kidney  or  of  the  growth  with  pus  in 
the  urine,  and  absence  of  any  large  amount  of  blood. 
This  disease  is  invariably  fatal. 

PYELITIS. 

By  pyelitis  is  understood  an  inflammation  of  the 
mucous  membrane  of  the  pelvis  of  the  kidney.  It  is 
usually  caused  by  the  irritation  of  calculi  or  by  some 


126  TREATISE   ON    MEDICAL   EXAMINATION. 

obstruction  in  the  ureter,  bladder,  or  urethra.  It  may 
also  be  due  to  an  extension  from  the  bladder  of  the 
inflammatory  process.  There  is  constant  lumbar  pain 
increased  by  pressure  and  extending  along  the  ureter 
into  the  groin.  The  urine  contains  pus  and  sometimes 
blood.  The  diagnosis  between  cystitis  and  pyelitis  is 
often  very  difficult.  The  character  of  the  epithelium 
found  is  one  thing  that  will  aid  in  determining  it.  No 
applicant  with  pyelitis  should  be  accepted. 

CALCULI  IN  THE  KIDNEY. 

Calculi  may  be  deposited  in  the  parenchyma,  calices, 
or  pelvis  of  the  kidney.  The  most  common  form  is 
the  uric  acid  calculus,  next  the  oxalic,  and  lastly  the 
phosphatic.  Pyelitis  and  hsematuria  are  ordinarily 
associated.  We  find  pain  in  the  lumbar  region,  per- 
haps tenderness.  Sometimes  the  pain  markedly  ex- 
acerbates when  the  patient  makes  a  misstep  or  jumps. 

It  passes  along  the  course  of  the  ureter  and  may 
extend  to  the  head  of  the  penis.  The  desire  for 
micturition  is  frequent,  and  the  urine  usually  contains 
pus,  blood,  albumen,  and  crystals.  Any  such  applicant 
is  disqualified  for  insurance. 

RENAL  COLIC. 

This  affection  is  mainly  caused  by  the  passage  of 
calculi  from  the  kidney  to  the  bladder.  The  com- 
mencement of  the  attack  is  very  acute  and  unattended 
by  febrile  disturbance.  The  pain  is  intense,  lancinating 
or  tearing  in  character,  felt  opposite  the  last  dorsal 


H^MATUKIA.  127 

and  first  lumbar  vertebrae  on  one  side  only,  and  shoot- 
ing thence  along  the  ureter  into  the  groin  and  thigh. 
In  the  male,  the  pain  is  also  felt  in  the  testicle  and 
that  organ  is  retracted.  The  face  evidences  the  severity 
of  the  suffering.  Nausea,  vomiting,  coldness  of  the 
surface,  and  a  feeble  circulation  are  among  the  accom- 
panying symptoms.  The  urine  is  much  lessened  in 
quantity  and  voided  a  few  drops  at  a  time.  It  is 
frequently  bloody,  and,  if  pyelitis  or  cystitis  co-exists, 
contains  pus.  When  the  calculus  reaches  the  bladder, 
the  attack  ends  as  suddenly  as  it  commenced.  An 
applicant  who  has  once  had  renal  colic  is  liable  to  be 
subject  to  it :  hence  all  such  must  be  refused. 

H^EMATUKIA. 

Blood  in  the  urine  may  come  from  the  kidneys, 
bladder,  or  urethra,  and,  in  females,  from  the  uterus  or 
vagina  as  well.  When  the  quantity  of  blood  is  small 
the  urine  will  have  a  smoky  appearance,  while  a 
larger  quantity  will  cause  more  or  less  red  discolora- 
tion. It  is  important  to  determine  from  what  portion 
of  the  urinary  tract  the  blood  is  derived.  If  from  the 
kidney,  it  is  uniformly  mixed  with  the  urine,  and  is 
rarely  clotted.  When  clots  do  occur  they  are  usually 
decolorized  before  being  passed.  Then,  too,  we  find 
evidences  of  some  kidney  lesion.  The  pain  is  chiefly 
in  the  lumbar  region  and  the  epithelium  is  of  the 
varieties  peculiar  to  the  kidney.  Calculi,  congestion, 
and  degenerative  disease  of  the  kidney  are  the  common 
causes  of  renal  hsematuria. 

When  the  blood  proceeds  from  the  bladder,  the  first 


128  TREATISE   ON   MEDICAL   EXAMINATION. 

portions  of  the  urine  passed  may  be  clear  or  nearly 
clear,  but  at  the  end  of  the  act  more  or  less  blood  in 
liquid  or  clotted  form  comes  away.  The  symptoms 
point  to  the  bladder  rather  than  to  the  kidney.  Cystitis, 
acute  or  chronic,  the  presence  of  a  calculus,  foreign 
growths  in  the  bladder,  sometimes  gout,  are  among  the 
causes  of  this  form.  Sometimes  the  hemorrhage  seems 
to  be  vicarious. 

Blood  from  the  urethra  is  passed  at  the  beginning  of 
the  act  of  micturition.  There  is  always  evidence  of 
local  trouble  found  upon  examination.  An  examina- 
tion of  uterus  and  vagina  will  also  exclude  these 
sources  of  hemorrhage. 

Unless  the  blood  in  the  urine  can  be  traced  to  some 
unimportant  cause,  the  applicant  had  better  be  refused. 

CHKONIC  CYSTITIS. 

Chronic  inflammation  of  the  mucous  membrane  of  the 
bladder  will  sometimes  be  brought  to  the  notice  of  the 
examiner.  It  is  usually  the  result  of  some  obstacle  to 
the  free  passage  of  the  urine,  such  as  vesical  calculus, 
stricture  of  the  urethra,  disease  of  the  prostate,  paralysis 
of  the  bladder,  etc.  The  disease  is  most  common  in 
elderly  people.  The  symptoms  are  dull  pain  in  the 
hypogastric  region,  frequent  and  painful  micturition, 
while  the  urine  contains  increased  phosphates,  mucus, 
and  pus.  The  sediment,  after  the  urine  has  stood  for 
some  time,  is  thick  and  viscid,  adhering  to  the  bottom 
of  the  vessel.  If  ulceration  of  the  mucous  membrane 
has  taken  place  there  will  also  be  more  or  less  blood. 
Usually  added  to  the  local  symptoms  we  find  consider- 


DIABETES.  129 

able  constitutional  disturbance.     Chronic  cystitis  is,  of 
course,  a  bar  to  insurance. 


DIABETES. 


This  term  is  now  restricted  to  a  greatly  increased 
flow  of  urine  containing  sugar.  The  disease  has  been 
in  the  past  one  of  the  banes  of  insurance  companies. 
Coming  so  insidiously,  so  unaccompanied  by  general 
symptoms,  as  is  frequently  the  case,  the  examiner  must 
challenge  its  existence  in  every  applicant.  Sometimes 
the  most  robust  and  vigorous,  to  all  appearances,  are  the 
very  ones  to  fall  its  victims.  The  man  with  diabetes  is 
in  a  state  of  chronic  weariness.  He  is  fatigued  with- 
out adequate  cause.  He  drinks  more  than  he  has  been 
in  the  habit  of  doing,  and  notices  that  he  has  to  urinate 
more  frequently.  His  skin  is  dry  and  harsh.  His  ap- 
petite is  never  satisfied,  but  in  spite  of  this  he  decreases 
in  weight.  His  mouth  is  dry.  His  tongue  is  red 
and  slightly  coated,  or  abnormally  clean,  dry,  and 
fissured.  His  gums  are  softened,  sometimes  pale,  some- 
times red,  and  bleed  easily  on  pressure.  Even  his 
breath  has  a  sweetish  odor.  As  the  disease  advances 
there  is  loss  of  Asexual  desire  and  power.  More  or  less 
digestive  disorder  exists.  A  tendency  to  boils  and  car- 
buncles manifests  itself,  and  the  slightest  scratch  heals 
with  difficulty.  Upon  the  examination  of  the  urine 
we  must  place  our  chief  reliance.  We  find  it  greatly 
increased  in  quantity,  sometimes  to  the  extent  of  thirty 
pints  or  more  in  the  twenty-four  hours.  Its  color  is 
pale,  sometimes  with  a  greenish  tinge.  It  has  a  sweetish 
smell  and  a  sweet  taste.  The  reaction  is  usually  feebly 


130  TKEATISE   ON   MEDICAL   EXAMINATION. 

acid,  while  the  specific  gravity  ranges  from  1025  to 
1060.  Testing  it  as  before  described,  we  find  evidence 
of  sugar  in  greater  or  less  amount.  It  occasionally 
happens  that,  after  periods  of  severe  mental  exertion 
or  anxiety,  small  amounts  of  sugar  may  be  transiently 
present  in  the  urine.  Such  cases  may  be  re-examined 
after  a  time,  and,  if  it  can  be  proved  that  the  sugar  has 
disappeared  from  the  urine,  may  be  accepted,  all  else, 
of  course,  being  favorable.  No  applicant  whose  urine 
persistently  contains  sugar  should  be  even  thought  of 
for  insurance. 

The  examiner  should  employ  all  possible  means 
towards  ascertaining  the  presence  of  diabetes  in  its 
earlier  stages.  The  interests  of  insurance  companies 
have  been  and  are  so  affected  by  it  that  it  is  now  a 
matter  of  the  utmost  concern,  and  we  therefore 
submit  the  following  questions  as  a  basis  for  the 
examiner  in  ascertaining  the  correct  symptoms  and 
reaching  a  safe  conclusion : 

1.  Does  the  applicant  suffer  from  any  nervous  dis- 
order ? 

2.  Is  he  irritable  in  temper? 

3.  Does  he  complain  of  fatigue  and  have  inclination 
to  sleep  ? 

4.  Is  he  troubled  with  disordered  vision  ? 

5.  Has  he  continued  headache  ? 

6.  Does  he  suffer  from  neuralgic  pains  without  any 
special  cause? 

7.  Has  he  any  skin  disease  or  eruption? 

8.  Is  he  occasionally  troubled  with  boils  and  car- 
buncles ? 

9.  Does  he  experience  want  of  virility  ? 


THE   INSURANCE    OF   WOMEN.  131 

10.  Does   he    have    an    insatiable   thirst    and   dry 
mouth  ? 

11.  Does  he  have  aphthous  ulcers  in  the  mouth  and 
on  the  tongue  ? 

12.  Does  he  suffer  from  dyspepsia  and  irregular  ap- 
petite ? 

13.  Has  he  frequent  inclination  to  pass  urine  ? 

14.  Is  the  quantity  passed  large? 

We  believe  that  in  the  case  of  every  applicant 
for  life  insurance  the  urine  should  be  tested  for 
sugar,  with  especial  care  should  the  specific  gravity 
be  above  1025. 

THE  INSURANCE  OF  WOMEN. 

As  the  special  points  in  the  examination  of  women 
have  mainly  reference  to  the  genito-urinary  organs,  we 
shall  here  introduce  what  we  have  to  say  upon  the  sub- 
ject. 

The  expectation  of  life  in  females  is  about  three 
years  in  advance  of  that  in  males.  It  would  seem  that 
the  particular  diseases  and  dangers  to  which  women  are 
liable  are  fully  counterbalanced  by  the  increased  hard- 
ships and  exposure  of  the  stronger  sex.  We  shall  give 
as  concisely  as  possible  a  few  hints  to  the  examiner. 

In  child-bearing  the  ratio  of  mortality  among  primi- 
parse  considerably  exceeds  that  among  multipart.  If 
the  applicant  should  prove  to  be  in  her  first  pregnancy 
the  examiner  should  postpone  all  proceedings  till  de- 
livery shall  have  safely  taken  place,  unless  some  special 
understanding  with  the  company  shall  have  been  en- 
tered into.  All  cases  in  which  the  first  parturition  has 


132  TREATISE   ON   MEDICAL   EXAMINATION. 

not  been  properly  completed  must  be  considered  extra 
hazardous. 

The  multipara,  on  the  other  hand,  is  not  so  objec- 
tionable a  risk.  Simple,  normal  labor  does  not  affect 
materially  the  duration  of  woman's  life,  unless  the 
number  of  pregnancies  should  be  unusually  large.  In- 
quiry should  be  made  as  to  the  character  of  previous 
labors,  and  if  all  has  been  favorable  the  applicant  may 
reasonably  be  insured.  At  the  present  time,  when  the 
forceps  are  used  by  many  practitioners  at  every  oppor- 
tunity, the  use  of  instruments  does  not  necessarily 
argue  an  abnormal  labor.  If,  however,  it  is  learned 
that  malpresentation  has  several  times  occurred,  or- that 
the  circumstances  of  the  labor  have  been  such  as  to 
indicate  pelvic  deformity,  the  examiner  should  be  very 
guarded  in  expressing  his  decision.  A  history  of  post- 
partum  hemorrhage,  puerperal  fever,  convulsions,  or 
puerperal  mania  seriously  impairs  the  value  of  the  risk. 
Of  course  it  is  understood  that  the  statements  hereto- 
fore made  presuppose  the  applicant  to  be  still  within 
the  child-bearing  period. 

Miscarriage  may  be  the  result  of  many  causes,  but 
recurring  miscarriages  should  suggest  to  the  examiner 
syphilis,  misplacement  or  disease  of  the  uterus,  or  me- 
chanical or  medical  means  used  to  bring  about  such 
result.  No  applicant  in  whom  the  habit  of  miscarriage 
is  found  should  be  accepted. 

In  the  case  of  women  at  the  climacteric  period,  the 
examiner  should  make  careful  inquiry  regarding  the 
difficulties  and  special  conditions  attending  this  func- 
tional change,  and,  if  he  should  discover  any  marked 
disturbance  in  general  health,  the  question  of  insurance 


THE   INSURANCE   OF   WOMEN.  133 

should  be  held  in  abeyance  until  this  period  shall  have 
been  safely  passed.  With  regard  to  the  uterus,  every 
abnormal  condition  must  be  properly  noted  and  its 
value  estimated.  Where  the  trouble  is  slight  and  there 
is  no  constitutional  disturbance,  it  may  be  practically 
overlooked,  but  where  such  disturbance  exists,  especially 
if  the  disease  is  of  such  a  character  as  to  gain  ground 
as  the  years  go  by,  the  examiner,  cannot  be  too  cautious. 
Recurring  hemorrhages  and  organic  disease,  or  tumors 
of  uterus  or  ovaries,  demand  unqualified  rejection. 
Vesico-vaginal  fistula  and  severe  lacerations  should  not 
be  accepted. 

Chronic  metritis  or  endometritis  and  subinvolution 
of  the  uterus  are  frequently  causes  of  great  impairment 
of  the  health  of  the  applicant,  and  should  defer  the  ac- 
ceptance of  the  risk  till  marked  improvement  has  taken 
place. 

Profuse  leucorrhoea  and  varicose  veins  should  not  be 
overlooked  in  estimating  the  true  value  of  the  risk. 


PART  VI. 

DISEASES  OF  THE  BLOOD 

AND  BLOOD-MAKING 

OEGANS. 


Most  diseases  of  the  blood  are  due  to  an  abnormal 
condition  or  relation  of  the  blood  constituents,  depend- 
ing upon  want  of  proper  assimilation,  poisons  carried  into 
the  system  from  without,  hereditary  predisposition  or 
diathesis,  or  disease  of  certain  important  organs. 

ANJEMIA. 

Anaemia,  or  poverty  of  the  blood,  may  be  the  result 
of  exhausting  discharges,  imperfect  hygienic  conditions, 
poor  assimilation,  or  such  diseases  as  tuberculosis, 
cancer,  glandular  affections,  Bright's  disease,  hepatic 
cirrhosis,  malaria,  lead  poisoning,  etc.  In  all  cases 
there  is  a  deficiency  in  the  red  blood  corpuscles.  We 
notice  as  the  prominent  symptoms  general  pallor  of  the 
face  and  body  surface.  The  ears,  if  held  to  the  light, 
are  devoid  of  the  normal  pink  tinge.  Lips,  tongue,  and 
gums  are  all  lacking  in  color.  The  hands  and  feet  are 
apt  to  be  cold  and  moist.  Exercise  readily  causes 
fatigue,  and  palpitation  and  shortness  of  breath 'occur 

135 


136  TREATISE   ON   MEDICAL    EXAMINATION. 

after  comparatively  slight  effort.  The  pulse  is  weak 
and  more  rapid  than  in  health.  Sometimes  anaemic 
murmurs  are  heard  over  the  base  of  the  heart,  and  the 
venous  hum  in  the  vessels  of  the  neck.  The  appetite 
is  poor  and  the  bowels  usually  costive.  Headache  and 
mental  inertia  are  common.  It  does  not  necessarily 
follow  that  anaemic  persons  are  lacking  in  fat.  In  some 
cases  quite  the  contrary  is  true.  The  examiner  will 
meet  this  condition  in  all  degrees,  and  wherever  well 
marked  he  should  carefully  inquire  into  the  under- 
lying cause.  No  applicant  who  is  at  the  time  of  ex- 
amination noticeably  anemic,  should  be  passed. 

PLETHORA. 

Plethora,  or  the  superabundance  of  red  blood  cor- 
puscles, is  not  so  frequently  encountered  as  the  pre- 
ceding condition.  Its  causes  may  be  found  in  inherited 
predisposition,  generous  living  with  insufficient  exer- 
cise, or  the  suppression  of  habitual  or  periodical  dis- 
charges. The  symptoms  are  the  reverse  of  those  of 
anaemia.  The  complexion  is  florid,  and  the  blood 
vessels  stand  out  prominently.  The  impulse  of  the 
heart  is  forcible,  the  pulse  firm,  full,  and  incompress- 
ible. Both  body  and  mind  are  active.  Feeling  of  ful- 
ness and  pain  in  the  head  are  readily  induced  by 
stimulants  or  mental  excitement.  Digestion  is  usually 
well  performed.  The  urine  contains  an  excess  of  urates, 
and  there  is  frequently  a  tendency  to  frank  or  sup- 
pressed gout.  In  such  individuals  acute  inflammations 
tend  to  a  sthenic  type.  If  such  condition  be  not 
remedied  by  careful  living,  sooner  or  later  atheromatous 


LETJCOCYTHJEMIA.  137 

change  in  the  vessels  takes  place.  Some  cerebral  vessel 
yields  to  the  pressure  of  the  forcible  blood  current,  and 
apoplexy  is  the  result. 

We  would  not  say  that  every  plethoric  applicant  is  a 
poor  risk.  The  man  of  full  habit  may,  by  temperance 
in  eating  and  drinking,  carefully  regulated  physical 
exercise,  and  systematic  habits,  live  to  a  hale  and  hearty 
old  age.  But  wherever  such  applicant  i§  considerably 
above  the  maximum  allowed  weight  and  is  addicted  to 
the  full  pleasures  of  the  table  and  to  the  use  of  alcoholic 
or  malt  liquors,  there  is  no  question  as  to  the  advisa- 
bility of  rejection. 

LEUCOCYTH^EMIA. 

\ 

Leucocythsemia  or  leukaemia  consists  in  the  enormous 
increase  of  the  white  corpuscles  in  comparison  with  the 
red.  Instead  of  the  normal  ratio  of  one  white  to  about 
350  red,  the  white  may  even  equal  the  red  in  number. 
The  disease  is  associated  with  morbid  changes  in  the 
medullary  cavities,  the  lymphatic  glands,  or,  most  fre- 
quently, the  spleen.  The  prominent*  symptoms  are 
anaemia,  loss  of  strength,  nasal  or  intestinal  hemor- 
rhages, dyspnoea  without  chest  lesions,  bronchial  catarrh, 
and  diarrhoea,  together  with  lymphatic  tumors  and 
enlarged  liver  and  spleen.  The  microscope  furnishes 
the  surest  means  of  diagnosis.  The  disease  is  almost 
invariably  fatal. 


10 


138  TKEATISE   ON    MEDICAL   EXAMINATION. 

HODGKIN'S  DISEASE. 

Hodgkin's  disease,  or  pseudo-leukaemia,  closely  re- 
sembles in  its  symptoms  the  preceding  disease.  We 
find  anaemia,  diarrhoea,  dyspnoea,  lymphatic  tumors, 
and  enlarged  spleen,  but  the  white  blood  corpuscles  are 
not  relatively  increased.  This  disease  also  proves  slowly 
fatal. 

ADDISON'S  DISEASE. 

This  is  dependent  upon  a  fibro-caseous  degeneration 
of  the  supra-renal  capsules.  With  a  pearly  conjunctiva 
and  well  marked  anaemia  there  exists  a  peculiar  bronz- 
ing or  discoloration  of  the  skin,  best  seen  upon  the 
face,  neck,  upper  extremities,  flexures  of  the  axillae,  and 
genital  organs.  The  invasion  is  very  gradual.  The 
circulation  is  very  feeble,  and,  as  the  case  progresses, 
there  is  great  fatigue  on  slight  exertion.  Gastro-intes- 
tinal  disturbances  co-exist.  In  from  three  months  to 
three  years  the  disease  proves  fatal.  Of  course  the 
examiner  would  only  encounter  such  cases  in  the  earlier 
stages. 

PUKPUKA. 

The  blood  disease  called  purpura  exists  in  two  forms, 
the  simple  and  the  hemorrhagic.  In  the  first,  small 
quantities  of  blood  are  extravasated  beneath  the  skin, 
giving  rise  to  purplish  or  blackish  spots  of  variable  size. 
These  spots  are  unattended  by  itching  or  by  any  of 
the  symptoms  which  characterize  scurvy,  and  fade 
slowly,  as  a  bruise  fades. 


EHEUMATISM. 


139 


In  the  second  form  we  find  internal  hemorrhages  in 
addition  to  the  symptoms  before  named. 

Simple  purpura,  unattended  by  any  graver  disease, 
does  not  materially  impair  the  value  of  the  risk. 

On  the  other  hand,  no  applicant  with  the  hemor- 
rhagic  variety  should  be  accepted. 

AFFECTIONS  OF  THE  SPLEEN. 

True  inflammation  of  the  spleen  is  so  rarely  found 
that  it  is  not  needful  to  consider  it.  Enlargement  of 
the  organ  is  the  chief  abnormal  condition  encountered, 
and  usually  occurs  in  connection  with  such  other  dis- 
eases as  malarial  fevers,  cirrhosis  of  the  liver,  leuco- 
cythsemia,  and  pseudo-leucocythsemia.  In  all  such 
cases  the  prognosis  of  the  splenic  affection  is  the  prog- 
nosis of  the  disease  upon  which  it  depends. 


EHEUMATISM. 

Rheumatism  is  produced  by  the  presence  in  the  blood 
of  an  excess  of  lactic  acid,  and  mainly  affects  the  fibrous 
tissues.  In  many  cases  it  may  be  traced  to  a  special 
diathesis  or  inherited  predisposition.  It  may  be  con- 
sidered under  its  three  forms,  acute,  sub-acute,  and 
chronic.  The  manifestations  of  the  disease  are  so 
familiar  to  every  practitioner,  that  we  shall  not  attempt 
to  give  a  clinical  history,  but  merely  state  the  relations 
of  rheumatism  and  its  sequelae  to  the  subject  of  life 
insurance. 

In   the   case  of  persons  possessing  the  rheumatic 


140  TREATISE   ON   MEDICAL   EXAMINATION. 

diathesis,  the  danger  is  twofold :  first,  from  the  impair- 
ment of  vital  power,  and  second,  from  the  great  lia- 
bility to  heart  complications.  Each  succeeding  attack 
fixes  more  firmly  the  existing  pre-disposition,  so  that 
we  may  safely  affirm  that  an  applicant,  who  has  already 
had  rheumatic  fever  two  or  three  times,  will  again  suffer 
with  it  just  so  soon  as  the  favorable  conditions  for  its 
development  again  exist.  In  a  large  percentage  of 
cases  endocarditis  or  pericarditis  or  both  are  super- 
added  to  the  primary  disease.  The  damage  to  the 
cardiac  structures  resulting  from  these  complications 
may  not  be  manifest  for  years  after  the  acute  inflamma- 
tory trouble  has  subsided.  If  the  applicant  has  had 
one  attack  of  acute  articular  rheumatism  a  number  of 
years  prior  to  the  time  of  application,  and  if,  in  the 
interim,  he  has  shown  no  symptoms  of  the  recurrence 
of  the  disease,  and  if  his  heart  after  the  most  careful 
examination  gives  no  evidence  of  organic  lesion,  he 
should,  all  else  being  favorable,  be  accepted  as  a  fair 
risk.  When,  however,  the  disease  is  undoubtedly 
hereditary,  or  the  diathesis  fully  established  by  a  history 
of  repeated  attacks,  or  the  existence  of  valvular 
lesions  proved  or  strongly  suspected,  rejection  should 
be  unqualified. 

In  the  sub-acute  and  chronic  forms,  much  must  be 
left  to  the  judgment  of  the  examiner.  The  duration  of 
the  affection,  the  amount  of  impairment  in  the  general 
health,  the  deformities  produced,  and  the  complications 
must  all  be  taken  into  account.  Heart  affections  are  not 
so  liable  to  co-exist  as  in  the  acute  form.  Muscular 
rheumatism,  except  in  aggravated  cases,  will  not  reject. 


GOUT.  141 

It  is  important  that  the  examiner  should  investigate 
much  of  what  may  be  termed  by  the  applicant  "  rheu- 
matic." Thus,  he  will  often  find  a  so-called  "  rheuma- 
tism "  of  the  right  shoulder  to  be  of  hepatic  origin ; 
"  rheumatic  "  pains  in  the  limbs  to  be  due  to  commenc- 
ing locomotor  ataxia ;  "  rheumatic "  pains  along  the 
tibia  to  be  caused  by  syphilitic  periostitis. 

GOUT. 

Gout  is  dependent  upon  an  excess  of  uric  acid  in  the 
blood.  In  at  least  one-half  the  cases  the  influence  of 
heredity  as  a  pre-disposing  cause  can  be  clearly  traced. 
In  the  other  half  the  diathesis  is  acquired.  To  have 
had  gout  is  usually  regarded  as  a  mark  of  distinction 
rather  than  otherwise,  and  as  ensuring  exemption  from 
other  diseases.  But  this  notion  is  clearly  erroneous. 
It  is  true,  indeed,  that  many  a  man  who  has  his  occa- 
sional attack  lives  to  a  hale  and  hearty  old  age,  but  it  is 
equally  true  that  if  the  attacks  be  frequent  or  the  dis- 
ease tend  to  assume  a  chronic  form,  impairment  of  vital 
power  must  be  the  result.  Such  a  case  may  fall  an 
easy  prey  to  acute  disease,  or  become  subject  to  some 
one  of  those  more  chronic  disorders  that  prove  none  the 
less  fatal  because  progressing  slowly. 

The  habits  of  the  applicant  may  be  such  as,  in  great 
degree,  to  counter-balance  his  gouty  tendency;  for  here 
we  have  a  disease  in  which  abstemious  living  and  sys- 
tematic exercise  may  accomplish  much.  An  hereditary 
tendency  appearing  in  early  life  argues  an  unfavorable 
risk.  So,  too,  frequently  recurring  attacks,  or  the  dis- 


142  TREATISE   ON   MEDICAL   EXAMINATION. 

ease  in  chronic  form.  If  the  urine  be  of  low  specific 
gravity  and  deficient  in  urates,  especially  if  albumen  be 
present,  the  presumption  is  that  interstitial  nephritis 
co-exists. 

We  would  call  passing  attention  to  that  form  of  half- 
developed  gout  known  as  lithiasis.  Its  manifestations 
are  legion,  and  we  can  only  say  here,  as  in  many  other 
instances,  that  the  examiner's  own  discretion  must  be 
his  best  guide. 


PART  VII. 

DISEASES  OF  THE  NERVOUS 
SYSTEM. 


In  this  division  of  our  subject  there  are  many  acute, 
sub-acute,  and  chronic  diseases  that  so  manifestly  dis- 
qualify for  insurance  that  there  is  no  chance  that  those 
subject  to  these  diseases  will  ever  make  application 
to  the  examiner.  Such  cases,  accordingly,  do  not  de- 
mand consideration,  as  our  aim  is  to  treat  only  of  such 
disorders  as  do  not,  at  the  time  of  application,  markedly 
interfere  with  the  usual  mental  or  physical  occupation. 

HEADACHE. 

If  the  examiner  discovers  that  the  applicant  is  sub- 
ject to  this  affection,  he  should  not  rest  satisfied  until 
he  has  discovered  the  cause.  It  may  be  the  sign  of 
purely  functional  disorder  or  of  serious  organic  disease. 
It  is  a  constant  symptom  in  almost  all  inflammatory  or 
degenerative  changes  of  the  brain  substance  or  its  mem- 
branes. It  may  be  produced  by  congestion  or  anaemia. 
It  may  be  due  to  affections  of  the  eye  or  ear,  to  disor- 
dered digestion,  to  hepatic  congestion,  to  uterine  or 
ovarian  troubles,  to  neuralgia,  rheumatism,  or  gout,  to 
mental  exhaustion  or  bodily  fatigue,  or  to  the  accumu- 

143 


t 

144  TREATISE   ON    MEDICAL    EXAMINATION. 

lation  in  the  blood  of  such  a  poison  as  urea.  Some- 
times the  attack  seems  to  come  without  predisposing 
cause.  Of  course  the  prognosis  will  be  that  of  the'  dis- 
order upon  which  the  headache  depends. 

VERTIGO. 

Vertigo  may  proceed  from  organic  disease  of  the 
brain  or  may  be  of  eccentric  origin.  Centric  vertigo  is 
usually  objective,  the  idea  of  motion  being  attached  to 
surrounding  objects ;  while  vertigo  from  causes  external 
to  the  brain  is  apt  to  be  subjective,  the  patient  himself 
seeming  to  move.  In  centric  vertigo  closing  the  eyes 
relieves  the  symptom. 

The  disorder  may  be  associated  with  disease  of  the 
heart  or  liver.  Often  it  is  found  with  Bright's  disease. 
Probably  the  most  frequent  form  is  that  known  as 
"  stomachal  vertigo,"  due  to  digestive  trouble.  It  may 
be  caused  by  certain  eye  affections,  and  in  inflammation 
of  the  semicircular  canals,  called  "  Meniere's  disease," 
it  is  constantly  present.  When  the  precursor  of  epi- 
lepsy, as  it  sometimes  is,  temporary  unconsciousness  is 
also  found.  As  in  headache  so  also  in  vertigo,  the 
character  of  the  trouble  underlying  the  symptom  should 
form  the  real  ground  for  acceptance  or  rejection. 

APOPLEXY. 

It  is  not  within  our  province  to  present  a  general 
description  of  cerebral  hemorrhage.  We  desire  to 
speak  merely  of  such  premonitory  symptoms  and  causes 
as  are  of  interest  to  the  examiner. 


APOPLEXY.  145 

Apoplectic  tendencies  are  frequently  found  in  several 
generations  of  the  same  family,  in  fact  the  general  build 
and  physique  of  apoplectic  parents  are,  as  a  rule,  trans- 
mitted to  the  progeny.  The  apoplectic  is  usually 
markedly  plethoric,  of  florid  complexion  and  short, 
thick  neck.  There  are,  however,  many  exceptions  to  this 
rule,  for  degenerated  blood  vessels  and  the  conditions 
requisite  for  their  rupture  exist  also  in  those  who  present 
quite  the  opposite  build.  The  general  health  may  be 
apparently  good,  but  the  individual  may  suffer  with 
occasional  vertigo,  pain  and  fullness  in  the  head  after 
mental  exertion  or  stimulation,  tinnitus  aurium,  slight 
disorders  of  vision,  or  occasional  epistaxis.  Usually 
both  body  and  mind  are  sluggish.  When,  in  an  appli- 
cant of  forty-five  years  or  more,  we  find  such  symptoms 
associated  with  full  blood  vessels  and  a  forcibly  acting 
heart,  we  must  expect  sooner  or  later  atheromatous 
changes  in  the  vessels  and  apoplexy  as  a  possible. result. 
The  disease  may  also  be  dependent  on  organic  lesions 
of  the  heart,  lungs,  or  kidneys,  tumors  about  the  neck, 
and  suppression  of  habitual  discharges,  as  from  hemor- 
rhoids, fistulse,  etc. 

If  there  is  reason  to  anticipate  apoplexy  in  any  appli- 
cant he  should  be  promptly  rejected.  It  is  needless  to 
say  that  any  person  who  has  ever  presented  apoplectic 
symptoms,  whether  from  cerebral  hemorrhage,  throm- 
bosis, embolism,  or  any  other  cause,  no  matter  how 
complete  his  recovery  may  be,  is  unfitted  for  all  insur- 
ance. 


146  TREATISE   ON    MEDICAL    EXAMINATION". 

CHRONIC  CEREBEAL  SOFTENING. 

This  is  a  disease  of  the  brain  substance  due  to  in- 
flammatory changes  or  defective  nutrition.  It  most 
frequently  occurs  in  elderly  people  whose  health  has  for 
some  time  been  impaired,  so  that  the  examiner  will 
only  meet  with  it  in  its  earlier  stages. 

It  may  result  from  apoplexy,  thrombosis,  embolism, 
degeneration  of  the  cerebral  vessels,  meningitis,  concus- 
sion of  the  brain,  mental  shock,  great  anxiety,  or  pro- 
longed mental  over-exertion.  The  symptoms  are  by  no 
means  pathognomonic,  but  among  those  commonly 
found  in  the  early  stages  of  the  disease  are  headache, 
vertigo,  impaired  intelligence,  defective  memory,  nausea 
or  vomiting,  pricking  or  numbness  in  parts  of  the  body, 
perhaps  slight  palsies.  Sometimes  there  is  difficulty  in 
articulating  distinctly,  and  quite  frequently  there  is  a 
marked  change  in  the  general  temperament.  Some  of 
these  symptoms  may  be  of  use  in  making  a  diagnosis. 
If  the  examiner  feels  assured  that  the  disease  exists,  the 
applicant  must  be  rejected. 

TUMORS  OF  THE  BRAIN. 

Tumors  or  abnormal  deposits  of  scrofulous  or  syphil- 
itic origin  may  occasionally  be  found  within  the  cra- 
nium. They  are  always  more  or  less  connected  with 
such  symptoms  as  nausea,  violent  paroxysmal  headache, 
vertigo,  disorders  of  special  senses,  partial  paralysis, 
and  epileptiform  convulsions.  The  progress  of  these 
affections  is  apt  to  be  slow.  The  intelligence  may  re- 
main practically  unimpaired  till  late  in  the  case.  No 
such  application  should  be  accepted. 


LOCOMOTOK   ATAXIA.  147 

LOCOMOTOE  ATAXIA. 

Locomotor  ataxia  is  a  disease  produced  by  sclerosis 
of  the  posterior  columns  of  the  spinal  cord.  It  begins 
insidiously  and  progresses  slowly  and  is  apt,  in  its 
earlier  stages,  to  be  overlooked  by  the  examiner.  The 
person  affected  usually  complains  at  first  of  neuralgic 
or  rheumatic  pains  in  the  lower  extremities.  Some- 
times these  pains  are  piercing,  sharp,  shooting,  like,  elec- 
tric shocks.  With  them  may  be  associated  disturb- 
ances of  vision,  perhaps  some  paralysis  of  the  third  or 
sixth  pair  of  nerves.  Soon  the  want  of  power  to  co- 
ordinate and  direct  movements  makes  its  appearance, 
shown  in  the  impaired  gait,  and  the  inability  to  stand 
or  walk  with  the  eyes  shut.  The  ordinary  walk  is  that 
of  one  whose  feet  are  both  asleep.  With  this  evident 
paralysis,  however,  the  muscles  are  well  nourished  and 
respond  well  to  electricity.  The  patient  can  kick 
vigorously,  thus  showing  that  the  motor  functions  of 
the  cord  are  not  seriously  impaired.  Sensibility  is 
greatly  diminished,  and  the  tactile  sensibility  is  almost 
lost.  The  ground  does  not  feel  hard  and  solid  to  the 
feet.  There  is  a  peculiar  girdle-like  feeling  about  the 
waist.  The  mind  is  unaffected.  Loss  of  sexual  power 
may  be  found  early  in  the  case.  Later,  progressive 
loss  of  sight  and  hearing,  difficult  articulation,  atrophy 
of  the  muscles,  dropsy,  and  swelling  of  the  joints  may 
occur. 

The  prognosis  is  most  unfavorable.  No  applicant  in 
whom  the  symptoms  are  at  all  suspicious  should  be 
accepted. 


148  TREATISE   ON    MEDICAL   EXAMINATION. 

TEEMOE. 

Tremor  may  sometimes  be  observed  in  parties  who 
apply  for  insurance.  If  not  caused  by  advanced*  age,  or 
spinal  disease,  it  may  be  due  to  some  muscular  or  ner- 
vous enfeeblement,  or  to  the  abuse  of  alcohol,  coffee,  or 
opium.  Lead  and  mercury  will  also  produce  it. 

As  it  argues  an  impaired  vitality,  it  should  reject. 

PAEALYSIS. 

Any  person  who  has  once  had  an  attack  of  hemi- 
plegia  or  of  paraplegia,  no  matter  how  complete  may  be 
his  recovery,  is  unfitted  for  all  insurance. 

We  wish  to  speak  under  this  head  of  those  local 
palsies  affecting  a  limb,  a  portion  of  a  limb,  or  certain 
muscles  or  groups  of  muscles,  that  may  sometimes  be 
encountered.  Of  this  character  is  that  paralysis  of  the 
portio  dura  of  the  seventh  pair,  known  as  BeWs 
palsy ;  also  the  paralysis  of  the  radial  nerve  from  com- 
pression, or  the  wrist  drop  seen  in  lead  poisoning.  The 
muscles  of  the  eye,  pharynx,  larynx,  oesophagus,  the 
diaphragm,  in  fact  the  muscles  of  algnost  any  part  of 
the  body  are  liable  to  loss  of  power  from  special  causes. 
While  the  prognosis  is  good  in  many  of  these  affections, 
yet  it  is  better  to  postpone  the  acceptance  of  the  appli- 
cant until  the  good  results  of  proper  treatment  are  fairly 
manifested. 

EPILEPSY. 

Convulsions  of  epileptiform  character,  occurring  only 
in  infancy,  are  without  special  significance.  But  when- 
ever in  later  life  any  such  tendency  has  become  mani- 


INSANITY. 


149 


fest,  the  examiner  must  remember  that  the  danger  is 
twofold.  In  the  first  place,  recurring  epileptic  convul- 
sions are  hardly  compatible  with  a  condition  of  robust 
health.  More  or  less  impairment,  physical  and  mental, 
is  the  rule.  In  the  second  place,  the  danger  of  serious 
accident  during  the  convulsive  seizure  is  always  great. 
Even  if  a  long  period  of  immunity  has  intervened  be- 
tween the  last  attack  and  the  application  for  insurance, 
still  the  applicant  cannot  be  considered  a  first-class  risk, 
as  the  liability  to  recurrence  of  the  disease  always  exists. 


HYSTERIA. 

This  disease  is  confined  almost  exclusively  to  females. 
If,  in  spite  of  well  marked  symptoms,  the  general  health 
is  good,  and  there  seems  to  be  no  tendency  to  serious 
uterine  or  ovarian  disease,  the  applicant  may  be  taken 
as  a  fair  risk.  The  examiner  should  be  careful,  how- 
ever, to  accurately  discriminate  between  spinal  symp- 
toms or  paralysis,  referred  to  by  the  applicant  as  "  hys- 
terical," and  similar  symptoms  dependent  on  cerebral  or 
spinal  lesions.  Qf  course  in  the  latter  event  there  can 
be  no  insurance. 

INSANITY. 

It  is  not  to  be  supposed  that  any  agent  would  know- 
ingly bring  for  examination  an  insane  person,  and  yet 
it  may  occasionally  happen  that  cases  may  be  presented 
in  which  the  earliest  symptoms  are  beginning  to  be 
manifested.  It  is  the  duty  of  the  examiner  to  reject  all 
in  whom  he  may  find  any  evidence  of  unsound  mind. 


150  TREATISE   ON    MEDICAL   EXAMINATION. 

The  influence  of  insanity  in  the  parents  in  producing 
insanity  and  other  nervous  diseases  in  the  offspring  will 
be  spoken  of  in  another  place. 

SUJSTSTKOKE. 

Those  who  have  been  sun-struck  occasionally  recover 
so  as  to  regain  in  full  measure  the  health  previously 
enjoyed.  Frequently,  however,  the  tendency  of  such 
an  accident  is  to  impair  the  normal  working  power  of 
the  brain,  and  to  render  the  individual  peculiarly  sus- 
ceptible in  future  to  the  effect  of  heat.  Sometimes  a 
tendency  to  insanity,  epilepsy,  chronic  meningitis,  or 
paralysis  is  induced,  all  of  which  conditions  would  se- 
riously affect  the  tenure  of  life.  If  any  effects  are 
perceptible  after  the  lapse  of  a  considerable  period 
subsequent  to  the  attack,  the  safer  plan  will  be  to 
decline  the  risk. 


PART  VIII. 

HEREDITARY   TRANSMIS 
SIGN. 


The  fact  has  been  recognized  that  a  tendency  to  par- 
ticular diseases,  as  well  as  to  peculiar  physical  and 
mental  characteristics,  may  be  transmitted  from  parent 
to  offspring.  The  constitutional  legacy  that  every  man 
receives  from  those  who  have  gone  before,  should  be 
most  carefully  considered,  before  the  examiner  forms 
his  conclusions  with  reference  to  the  eligibility  of  the 
applicant.  The  inherited  taint  may  be  latent  for  years, 
perhaps  for  one  or  more  generations,  yet  no  sooner 
do  the  favorable  conditions  present  themselves,  than 
this  taint  develops  into  characteristic  and  formidable 
disease. 

The  tubercular  or  consumptive  taint,  pre-emi- 
nently to  be  feared  both  on  account  of  the  number 
of  cases  and  the  character  of  the  resulting  disease, 
above  all  others  should  first  receive  attention. 

1.  The  general  supposition  is  that  the  tendency  to 
and  the  development  of  consumption  is  more  frequently 
hereditary  than  acquired. 

2.  That  the  taint  is  transmitted  with  greater  viru- 
lence from  the  mother  than  from  the  fathej, 

151 


152  TREATISE   ON   MEDICAL   EXAMINATION. 

3.  That   the    tendency   is    intensified   when    both 
parents  are  previously  diseased. 

4.  To  transmit  the  tendency,  either  one  or  both  of 
the  parents  must  be  consumptive  previous  to  the  gene- 
ration of  the  offspring.     As  an  exception  to  this  rule 
must  be  cited  those  cases  in  which  the  inherited  disease, 
latent  in  the  children,  re-appears  in  the  grand-children. 

5.  The  transmitted  tendency  may   remain    latent 
during  a  life  of  many  years  and  never  develop  into 
consumption;    whereas,  again,  surrounding   influences 
may,  at   any  time,    arouse   and   stimulate   it   to   fatal 
activity. 

6.  Chronic  diseases  or  a  broken  down  constitution 
on  the  part  of  parents,  especially  when  far  advanced 
in  life,  may  predispose  the  offspring  to  the  development 
of  this  same  fatal  malady. 

7.  All  the  children  of  consumptive  parents  are  not 
equally  liable  to  this  disease,  since  those  born  in  the 
prime  of  the  parents'  life,  and  before  the  development 
of  the  disease  in  either  of  them,  may  be  of  hardier 
constitution   than   others  of  the  family,  born  at  later 
periods. 

8.  Consumption,  when  acquired  by  other  than  he- 
reditary transmission,  usually  does  not  develop  until  a 
later  period  of  life,  because  other  causes  must  first  pre- 
pare the  system  to  become  the  nursery  of  consumption. 

9.  If    pre-existing    in    the    system,    consumption 
usually  develops  much  sooner  in  those  who  are  sub- 
jected to  hard  labor,  than  in  those  whose  position  and 
resources  enable  them  to  avoid  the  fatigues,  exposures, 
privations,  and  other  exciting  causes,  which  tend  to 
impair  the  l^alth. 


HEREDITARY   TRANSMISSION.  153 

10.  Temperament,  however  favorable  otherwise,  does 
not  insure  any  person  from  falling  a  victim  to  consump- 
tion;   neither  will  bodily  conformation   prove  a   bar, 
since   both   men  and  women,    possessing   the  highest 
physical  development,  readily  succumb  to  this  disease. 
Hence  the  apparently  robust  physique  of  an  applicant 
is  not  an  invariably  sure  criterion  of  perfect  health, 
especially  when   there   exists   the  latent   tendency  to 
tuberculosis. 

11.  The   cause  of  death   of    the   parents   or   other 
members  of  the  family  requires  closer  attention  than  is 
usually  given,  since,  either  willfully  or  ignorantly,  this 
is  frequently  misrepresented.     It  is  well  to  bear  in  mind 
that  such  terms  used  by  the  applicant  as  "exposure  to 
cold,"    "childbirth,"     "inflammation    of    the    lungs," 
"debility,"  or  "do  not  know,"  express  nothing  definite 
and  require  further  investigation  in  order  to  ascertain 
the  requisite  details. 

12.  In  children  the  consumptive  taint  more  frequently 
develops  in  the  brain  or  in  the  abdominal  organs  than 
in  the  lungs.     If,  therefore,  brothers  or  sisters  of  the 
applicant  have  died  of  brain  or  abdominal  diseases  in 
early  childhood,  the  examiner   should   be   careful  to 
ascertain  whether  or  not  tuberculosis  was  the  cause. 

13.  The  consumptive  dyscrasia  may  course  through 
several  generations,  but  its  relative  virulence  can  best 
be  learned  from  its  apparent  influence  on  other  mem- 
bers of  the  applicant's  immediate  family. 

14.  The  influence  of  a  consumptive  father  is  most 
strongly  manifested  in  the  children  between  the  ages 
of  ten  and  thirty.     After  the  applicant  has  passed  the 
age  of  forty-five  the  danger  is  comparatively  slight. 

ii 


154  TREATISE   ON   MEDICAL   EXAMINATION. 

The  liability  may  extend,  however,  up  to  the  age  of 
sixty-five. 

15.  The  susceptibility  from  the  influence  of  a  con- 
sumptive mother  is  greater  than  from  the  influence  of 
the  father.     The  period  of  liability  is,  however,  shorter, 
for  after  forty  but  few  deaths  occur.     The  period  most 
to  be  dreaded  is  from-  fifteen  to  thirty.     The  disease  as 
transmitted  by  the  mother  is  also  apt  to  be  more  viru- 
lent in  type,  and  run  a  shorter  course,  than  in  cases  of 
paternal  heredity. 

16.  If,   in   a   numerous    family,   two    deaths    from 
phthisis  have  occurred,  the  one  a  parent  beyond  forty, 
the  other   a   brother   or   sister  below  the   applicant's 
present  age,  and  if  no  personal  objectionable  points 
exist,  the  risk  may  be  classed  as  moderately  fair. 

17.  A  single  death  of  brother  or  sister  in  a  family 
of  fair  size,  with  no  history  of  consumption  in  parents 
or  grand-parents,  and  with  personal  points  all  favor- 
able, should  not  prove  a  bar  to  insurance. 

18.  If  two  deaths  of  brothers  or  sisters  older  than 
the  applicant  have  taken  place  from  this  cause,  and  if 
the  personal  points  are  of  only  medium  average,  the 
risk  is  objectionable. 

19.  The  death  of  both  parents  from  consumption, 
even  at  an  earlier  age  than  that  of  the  applicant,  argues 
a  precarious  risk,  for,  of  course,  the  applicant  stands 
in  double  danger. 

20.  Three  or  more  deaths  in  the  immediate  family, 
including  a  parent  and  two  or  more  brothers  or  sisters 
older  than  the  applicant,  personal  points  being  favor- 
able, disqualify  for  insurance. 

21.  When  no  death  in  the  family  has  occurred,  but 


HEREDITARY    TRANSMISSION.  155 

the  personal  points  exhibit  marked  tendencies  to  the 
development  of  the  tuberculous  diathesis,  the  applicant 
should  not  be  insured. 

22.  When  infant  mortality  has  been  great,  and  the 
,  surviving  members  of  the  family  are  quite  young  and 

the  applicant  himself  be  young,  or  the  only  living 
member,  the  risk  is  at  best  hazardous. 

23.  The  death  from  consumption  of  a  grand-parent 
followed  by  that  of  father  or  mother  in  the  same  line, 
if  personal  points  in  the  applicant  are  very  good,  ren- 
ders the  risk  objectionable,  in  so  far  that  the  taint  is 
present   in   the   applicant's   system   and   may.  become 
developed  by  any  exciting  cause. 

24.  Although  the  consumptive  taint  is  more  certainly 
transmitted  by  the  mother  than  the  father,  at  the  same 
time,  however,  the  safest  prognosis   may  be  deduced 
from  the  striking  resemblance  which  the  applicant  may 
present  to  one  parent  above  the  other. 

25.  Both  parents  having  died  comparatively  young, 
one  from  consumption  and  one  from  cancer,  abscess, 
erysipelas,  intemperance,  heart  affection,  kidney  disease, 
or   insanity,   the    applicant    undoubtedly  carries   the 
transmitted  taint  of   one  or  both  parents,  and,  even 
with  the  best  personal  points  otherwise  exhibited,  must 
be  classed  a  poor  risk. 

26.  No  death  from  consumption  of  parent  or  children 
of  the  family  having  occurred,  it  becomes  unnecessary 
to  extend  the  investigation  farther  back.     But  should 
the  hereditary  taint  have  seriously  affected  the  life  of 
the  immediate  family,  it  becomes  the  examiner's  duty 
to  ascertain  the  cause  of  death  in  grand -parents,  uncles 
or  aunts,  and  immediate  blood  relations. 


156  TREATISE   ON    MEDICAL   EXAMINATION. 

27.  The  scrofulous  or  strurnous  diathesis  being  so 
frequently  and  distinctly  involved  in  the  consumptive, 
a  special  detail  of  it,  in  this  connection,  is  rendered 
unnecessary. 

Cancer.  In  the  category  of  taints,  next  to  the 
phthisical,  follows  the  cancerous.  In  case  that  both 
the  consumptive  and  cancerous  taints  are  found  in  the 
applicant's  family  or  its  collaterals,  it  is  presumable 
that  either  or  both  of  the  taints  are  lodged  in  the 
system,  and  the  risk  is  decidedly  poor;  nor  are 
the  applicant's  chances  better  if  two  or  more  deaths 
from  cancer  have  occurred  in  his  family.  We  would 
observe,  however,  that  in  rare  cases  the  disease  may 
be  only  sporadic,  resulting  altogether  from  a  depraved 
condition  of  the  system.  The  death  of  one  parent  would 
not  in  every  case  warrant  a  refusal  of  the  applicant. 

The  development  of  cancer  is  most  frequent  during 
the  years  between  thirty-five  and  fifty,  when  the  pro- 
cesses of  nutrition  begin  to  fail.  The  tendency  to 
cancer  is  greater  in  the  female,  and  the  reproductive 
organs  (including  the  mammae)  are  more  generally 
affected  than  other  parts  of  the  body.  The  examination 
must  be  thorough  whenever  the  family  history  im- 
plies the  presence  of  this  taint  in  the  applicant. 

Gout.  This  is  another  of  the  diseases  that  are  un- 
doubtedly hereditary.  It  is  believed  that  in  more  than 
one-half  of  the  cases  the  influence  of  the  inheritance 
can  be  clearly  traced.  Hence  the  need  of  a  careful 
investigation  of  the  family  record.  If  the  diathesis  is 
manifested  in  early  life,  the  risk  is  less  acceptable  than 
it  is  when  the  disease  occurs  for  the  first  time  at  a  com- 
paratively late  age. 


HEREDITARY   TRANSMISSION.  157 

Where  one  parent  or  a  grand-parent  has  been  subject 
to  gout — the  applicant  himself  having  never  experienced 
its  symptoms,  not  being  given  to  excesses  or  high  living, 
and  passing  a  satisfactory  examination  in  all  respects — 
no  objection  to  insuring  the  party  can  be  raised. 

Where  both  parents,  or  a  parent  and  a  grand-parent 
and  an  uncle  or  aunt,  have  been  sufferers,  the  chances 
of  life  are  impaired  and  the  risk  objectionable.  If,  how- 
ever, the  personal  examination  proves  highly  satisfac- 
tory and  the  applicant  has  passed  the  age  of  thirty-five 
without  showing  any  signs  of  the  disease,  insurance 
may  be  given. 

The  examiner  must  consider  that  the  inherited 
diathesis  does  not  always  indicate  its  existence  by  an 
attack  of  unmistakable  gout.  So  much  damage  may  be 
done  that  degenerative  changes  may  occur  in  heart, 
blood  vessels,  kidneys,  or  other  portions  of  the  body, 
and  yet  the  symptoms  may  be  only  those  of  the  so-called 
lithcemia. 

Rheumatism  exhibits,  in  a  somewhat  less  degree, 
the  same  tendency  to  hereditary  transmission  that  is 
found  in  gout.  Of  208  cases  investigated  by  Fuller, 
71  were  inherited.  The  predisposition  develops  itself 
most  markedly  between  the  ages  fifteen  and  thirty,  while 
after  fifty  the  liability  is  comparatively  very  slight. 

If,  with  a  family  history  of  acute  articular  rheuma- 
tism, the  applicant  has  himself  had  one  or  more  attacks, 
the  great  probability  is  that  future  attacks  will  occur, 
and  so  the  risk  is  at  best  a  hazardous  one.  If  the  age 
of  thirty-five  be  passed  without  any  manifestation  of  the 
disease,  there  is  no  reason  why  the  application  should 
not  be  accepted,  other  points  of  course  being  favorable. 


158  TREATISE   ON   MEDICAL   EXAMINATION. 

Cerebral  diseases,  such  as  apoplexy,  paralysis, 
epilepsy,  and  insanity,  are  undoubtedly  handed  down 
from  parent  to  child.  The  examiner  is  advised  to  weigh 
well  the  following  distinctive  points  : — 

1.  At  what  age  in  the  parent's  life  was  the  disease 
developed  ? 

2.  Did  it  originate  suddenly  from  grief  or  sickness, 
or  did  it  only  gradually  assume  severe  form  ? 

3.  Was  the  applicant  born  before  or  after  its  mani- 
festation in  the  parent  ? 

4.  When  born,  were  the  parents  in  perfect  health  ? 

5.  Is  any  other  member  of  the  applicant's  family 
laboring  under  a  cerebral  affection  ? 

The  hereditary  influence  does  not  always  transmit 
the  same  form  of  cerebral  disease,  but  the  various  forms 
appear  to  be  more  or  less  interchangeable.  Thus,  the 
parent  being  insane,  the  child  may  be  hysterical  or 
epileptic,  and  vice  versa. 

If  the  family  record  with  reference  to  brain  disease 
is  poor,  and  the  personal  examination  prove  other 
than  perfectly  satisfactory,  the  applicant  should  be 
declined. 

Syphilis  is  transmitted  by  either  father  or  mother, 
and  is  the  cause  of  much  infantile  mortality.  With 
favorable  surroundings,  it  may  sometimes  gradually 
disappear  before  the  individual  becomes  an  adult,  and 
may  show  no  evil  results  in  after  life.  The  examiner, 
in  such  cases,  will  be  obliged  to  rely  far  more  upon  his 
own  inferences  than  upon  the  statements  made  by  the 
applicant.  Should  the  applicant,  even  with  this  ante- 
cedent, be  found  to  be  personally  well  qualified  on  all 
points,  the  constitutional  impediment  would  be  insuffi- 


HEREDITARY   TRANSMISSION.  159 

cient  to  reject.     Of  course,  in  any  such  case,  the  exam- 
ination should  be  made  with  unusual  thoroughness. 

The  hereditary  form  of  syphilis  is  not  so  objection- 
able as  the  acquired  form.  In  insurance  work  the  latter 
is  far  more  to  be  dreaded,  and  unless  the  applicant  can 
adduce  conclusive  evidence  that  he  has  undergone 
proper  treatment  for  the  suitable  number  of  years,  and 
since  the  cessation  of  the  treatment  has  been  free  for 
several  years  from  every  manifestation  of  the  disease, 
no  case  of  the  acquired  form  should  be  even  considered. 

It  would  be  possible,  did  our  limits  permit,  to  trace 
the  hereditary  influence  in  the  development  of  diseased 
conditions  other  than  those  already  enumerated.  In 
considering  the  etiology  of  diseases  of  the  heart,  blood 
vessels,  stomach,  kidneys,  and  still  other  organs,  this 
pre-disposing  cause  demands  its  due  attention.  The 
truly  typical  conditions  have,  however,  been  stated,  and 
enough  has  been  said  to  impress  upon  the  examiner  the 
necessity  of  regarding,  not  merely  the  superficial  per- 
sonal characteristics  of  the  applicant,  but  also  that  sus- 
ceptibility to  certain  diseases  that  has  been  his  legacy 
from  his  ancestors. 


PART  IX. 

THE  PERFECT  AND  THE  IM- 
PERFECT MAN. 


THE  PEEFECT  MAN. 

Presupposing  the  reader  to  be  thoroughly  acquainted 
with  the  subjects  previously  discussed,  his  particular 
attention  has  yet  to  be  called  to  the  consideration  of  the 
man  in  his  entirety,  and  thence  to  the  delicate  duty  of 
summing  up  the  arguments  for  and  against  the  accept- 
ance of  the  risk.  This  highly  responsible  task  will 
often  prove  extremely  difficult,  and  require  a  long 
experience  and  the  best  professional  skill  for  its  satis- 
factory accomplishment.  In  frequent  instances,  points 
for  investigation  will  obtrude  themselves,  which  demand 
both  caution  and  clear  insight  in  order  to  properly 
grasp  their  true  character  and  aggregate  relative  sig- 
nificance. The  observations  which  we  here  subjoin  are 
by  no  means  designed  to  take  the  place  of  rigid  rules, 
but  simply  to  offer  hints  that  may  stimulate  that  clear- 
ness of  mental  vision  and  that  comprehensiveness  of 
grasp  that  the  physician  should  be  ready  to  exercise  upon 
every  occasion.  Good  judgment,  moderation,  and  hon- 
esty of  purpose  should  be  so  combined  as  to  avoid  dis- 
couraging or  offending  the  applicant,  while,  at  the  same 

161 


162        'TREATISE  ON  MEDICAL  EXAMINATION. 

time,  all  seemingly  serious  conditions  should  be  given 
the  clear,  pointed  investigation  which  they  demand. 

To  illustrate,  we  assume  that  the  applicant  represents 
in  his  person  the  perfect  man,  an  individual  whose  sys- 
tem is  devoid  of  any  inherited  taint  or  actual  lesion 
which  could  lessen  the  anticipation  of  his  probable  life 
tenure.  To  prove  that  our  applicant  is  really  what  he 
seems,  we  proceed  to  examine  first,  let  us  say,  his  age. 
The  actual  age  must  so  agree  with  the  apparent  age  as 
in  no  wise  to  cast  doubt  upon  the  fulfillment  of  the 
proper  life  expectation.  Of  course,  if  he  be  older  than 
he  appears,  the  indication  is  favorable  rather  than 
otherwise. 

Few  pass  through  childhood  and  the  earlier  years  of 
adult  life  without  experiencing  some,  at  least,  of  the 
more  ordinary  diseases.  But  in  our  applicant,  such 
diseases,  if  they  have  existed,  have  come  and  gone 
leaving  no  traces  of  mischief  behind. 

"We  shall  expect  to  find  that  his  family  history  is  of  the 
best ;  that  his  grand-parents  died  at  advanced  ages  or 
from  acute  diseases;  that  the  parents  are  still  living 
and  in  the  enjoyment  of  good  health,  or,  perhaps,  have 
died  from  such  affections  as  would  not  tend  to  reappear 
in  the  children ;  that  no  marked  mortality  exists 
among  brothers  and  sisters,  and  that  those  living  are 
healthy.  With  such  a  family  record  no  fault  can  be 
found. 

The  hair,  both  in  color  and  condition,  should  be  in 
perfect  accord  with  the  tale  of  years.  The  eye,  too, 
must  be  healthful,  clear  and  sparkling,  and  void  of  any 
indication  of  intemperance,  consumption,  Bright's 
disease,  insanity,  or  other  affection.  The  face  must  be 


THE    PERFECT    MAN.  163 

free  from  the  characteristic  expression  that  accompanies 
so  many  organic  diseases,  and  the  complexion  must  show 
no  trace  of  past  or  present  ailment. 

There  must  be  nothing  prejudicial  to  health  in  the 
place  of  residence  or  the  character  of  the  occupation. 

Passing  now  to  personal  development,  our  applicant 
must  be  properly  proportioned  in  all  parts,  and  without 
malformation.  Height  and  weight  must  be  relatively 
so  balanced  within  the  allowed  limits  as  to  afford  no 
abnormal  deviation  from  standard  rules,  and  the  chest 
development  should  agree  with  both  height  and  weight. 
Eyesight  and  hearing  must  be  so  good  as  to  insure  the 
individual  against  the  increased  risks  that  the  marked 
impairment  of  either  sense  involves. 

The  pulse  should  be  soft  yet  full,  evidencing  normal 
heart  powers  and  undegenerated  arterial  walls.  The 
rate  should  be  between  65  and  75  per  minute,  although 
there  are  many  exceptions  to  this  rule,  dependent  upon 
bodily  formation,  peculiar  temperament,  or  individual 
idiosyncrasy.  It  should  be  neither  irregular  nor  inter- 
mittent, but  should  be  uniform  throughout  the  trial. 

By  percussion,  we  must  find  that  the  area  of  heart 
dullness  is  not  increased  and  that  the  organ  does  not 
unduly  approach  the  thoracic  parietes.  By  palpation, 
we  must  discover  the  impulse  to  be  of  proper  force  and 
not  extended  beyond  the  normal  limits.  By  auscul- 
tation, we  must  prove  the  sounds  normal  and  of  the 
character  before  described,  free  from  roughness  or  any 
suspicion  of  a  murmur.  We  learn  that  the  applicant 
suffers  from  neither  palpitation  nor  dyspnoea. 

The  careful  examination  of  the  thorax  reveals  the 
fact  that  the  chest  is  symmetrical  and  well  developed. 


164  TREATISE  ON   MEDICAL   EXAMINATION. 

Measurement  shows  the  proper  difference  between 
forced  expiration  and  forced  inspiration.  The  respira- 
tory movements  are  full  and  regular  throughout  the 
two  lungs  and  the  number  of  respirations  averaging 
eighteen  or  twenty  per  minute.  The  chest  is  normally 
resonant,  with  no  tendency  to  dullness  on  the  one  hand 
or  tympany  on  the  other.  The  air  is  heard  to  freely 
enter  all  parts  of  the  lung  tissue,  producing  the  proper 
vesicular  murmur,  without  the  admixture  of  adventi- 
tious sounds.  Vocal  resonance  and  vocal  fremitus  are 
neither  suppressed  nor  exaggerated  at  any  point.  Find- 
ing all  these  conditions  present,  we  are  justified  in  the 
belief  that  no  serious  disease  of  heart  or  lungs  exists. 

Turning  next  to  the  digestive  organs,  we  must  find 
that  the  tongue  presents  the  normal  appearance,  that 
digestion  is  easily  and  painlessly  performed,  that  there 
is  no  tendency  to  constipation  or  diarrhoea,  that  spleen 
and  liver  are  not  diseased,  and  that  the  size  of  the 
abdomen  corresponds  with  the  age  of  the  applicant  and 
his  general  physical  development. 

In  the  examination  of  the  kidneys  and  urinary  organs 
we  must  not  be  content  with  the  absence  of  all  symp- 
toms that  would  indicate  disease  of  these  organs,  but 
must  in  each  case  carefully  examine  the  urine.  It  must 
be  of  proper  specific  gravity  and  reaction,  and  free  from 
sugar,  albumen,  pus,  blood,  tube  casts,  or  any  other 
abnormal  constituent.  Only  thus  can  we  feel  at  all 
certain  that  no  latent  lesion  exists. 

To  prove  the  person  free  from  any  nervous  affection, 
he  must  be  alert,  with  vigorous  gait,  and  well  co-ordi- 
nated movements,  and  show  the  evidence  of  a  sound 
mind  in  a  sound  body.  All  gestures  should  be  natural 


THE   IMPERFECT    MAN. 


165 


and  all  musciflar  action  free  from  any  trace  of  paralysis 
or  other  lesion,  out  of  which  cerebral  or  spinal  disease 
might  eventuate. 

An  applicant  presenting  all  these  conditions  may  be 
regarded  as  the  ideal  insurance  risk. 


THE  IMPERFECT  MAN. 

We  have  just  been  considering  the  applicant  whose 
personal  condition  and  family  history  are  in  every  way 
favorable  for  acceptance.  We  turn  next  to  the  con- 
verse, that  far  more  numerous  class,  whose  lines  of 
defence  against  the  attacks  of  disease  have  already  been 
penetrated  at  one  or  more  points.  First  to  find  such 
assailable  points,  and  then  to  rightly  estimate  their 
importance  in  comparison  with  those  portions  of  the 
organism  still  intact,  must  be  the  evident  duty  of  each 
medical  examiner. 

Unfavorable  surroundings,  dependent  upon  either 
climate  or  occupation,  cannot  but  exert  a  prejudicial 
effect  upon  the  value  of  the  risk.  Sudden  and  extreme 
changes  in  temperature  greatly  influence  the  system 
both  by  developing  constitutional  and  engendering 
endemic  disease.  Residence  in  tropical  climates  must 
be  regarded  as  extremely  hazardous,  owing  to  the 
fatality  of  miasmatic  diseases. 

Any  business  that  may  tend  to  injure  the  health  of 
the  applicant,  or  expose  him  to  the  liability  of  accident 
or  to  temptation  to  indulgence  of  a  debasing  and  de- 
structive character,  argues  against  the  risk  in  proportion 
to  the  danger  attending  it. 

The  subject  of  inherited  taint  has  already  been  so 


166  TREATISE   ON    MEDICAL   EXAMINATION. 

fully  treated  that  it  is  only  necessary  hereto  emphasize 
the  importance  of  minute  inquiry  into  all  points  of 
family  history  that  might  prove  to  the  personal  disad- 
vantage of  the  applicant.  Against  an  unfavorable 
family  record  must  be  set  off  the  individual's  surround- 
ings, age,  personal  record,  and  present  condition. 

Next,  the  past  history  of  the  applicant  must  be 
critically  scrutinized.  The  occurrence  of  serious  disease 
of  the  chest,  nervous  system,  or  urinary  organs,  calls 
for  great  thoroughness  in  the  physical  examination,  for 
the  chances  of  imperfect  recovery  from  such  diseases 
should  always  be  borne  in  mind.  If  the  rheumatic 
or  gouty  diathesis  have  been  manifested,  the  soundness 
of  the  principal  organs  must  be  proved  before  accepting, 
if,  indeed,  the  risk  be  accepted  at  all. 

Turning  to  the  physical  examination,  if  the  age  in 
years  as  given  by  the  applicant  is  not  confirmed  but 
rather  contradicted  by  the  general  appearance,  the 
apparent  discrepancy  should  be  accounted  for,  as  other- 
wise the  inference  is  unfavorable.  The  features,  speech, 
gait,  movements  of  the  body,  and  other  circumstances, 
sometimes  seemingly  trivial  in  themselves,  should  be 
carefully  noted  as  helping  to  decide,  by  their  combined 
testimony,  at  what  period  the  decline  of  life  sets  in  and 
also  what  measure  of  life  may  probably  remain  in 
expectation. 

Premature  baldness,  unless  proved  to  be  a  family 
characteristic,  may  imply  the  presence  of  syphilitic  or 
other  taint.  Gray  hair,  under  like  circumstances,  sug- 
gests great  anxiety,  nervous  strain,  possibly  brain 
lesions.  Either  condition  calls  for  investigation. 

The  full,  congested  features  of  the  intemperate  man 


THE   IMPERFECT    MAN.  167 

are  easily  recognized.  The  sallow  complexion  with 
discolored  conjunctiva  points  to  hepatic  disorder.  The 
transparent  skin  with  localized  flush  shows  the  tuber- 
culous or  strumous  diathesis.  While  the  various  hues 
of  cachexise  indicate  chronic  organic  diseases  with  their 
deficiency  of  red  blood  and  their  excess  of  tissue  waste. 

Every  departure  from  the  normal,  strong,  bony  frame- 
work or  from  the  proper  muscular  development,  calls 
for  attention,  as  possibly  relating  to  some  existing  dis- 
ease. Malformation,  if  at  all  interfering  with  the  func- 
tions of  internal  organs  or  the  applicant's  ability  to  do 
for  himself,  disqualifies  for  insurance. 

It  is  well  known  that  those  much  above  or  below  the 
average  height  possess  comparatively  little  power  of 
endurance.  Other  things  being  equal,  such  men  are 
more  liable  to  drop  off  during  epidemics  or  when  at- 
tacked by  acute  disease. 

Corpulence,  when  in  marked  disproportion  to  height, 
is  unfavorable,  bespeaking,  in  the  majority  of  instances, 
the  habitual  use  of  stimulants,  sedentary  habits,  and 
over-indulgence  of  the  appetite.  Light  weight  is  still 
more  unfavorable,  for  the  great  number  of  death  claims 
from  chronic  wasting  diseases  occur  among  those  who 
are  fifteen  per  cent,  or  more  below  the  standard  weight. 
Loss  of  flesh  without  evident  cause  should  always  be 
regarded  with  suspicion. 

Blindness  and  deafness,  whether  singly  or  combined, 
not  only  expose  the  applicant  to  more  than  ordinary 
danger  of  accident,  but  may  so  interfere  with  necessary 
physical  exercise  as  to  impair  the  health.  Either  con- 
dition, therefore,  materially  increases  the  risk. 

Hernia,  if  easily  reducible  and  supported  by  a  prop- 


168  TREATISE   ON   MEDICAL    EXAMINATION. 

erly  fitting  truss,  does  not  prevent  insurance.  If,  how- 
ever, it  is  not  reducible,  or  the  applicant  refuses  to  wear 
a  truss,  the  danger  of  strangulation  should  always  be 
considered.  For  this  reason  the  examiner  would  be 
justified  in  declining  the  risk. 

No  applicant  with  fistula  in  ano  should  be  accepted 
until  the  fistula  is  healed.  Even  then  the  examiner 
must  be  convinced  that  the  local  lesion  has  not  been 
associated  with  or  dependent  upon  the  strumous 
diathesis  or  constitutional  disease. 

Piles,  unless  of  very  severe  form,  would  not  alone  be 
sufficient  to  reject.  They  usually  result  from  inactivity 
of  the  liver,  from  digestive  disorders,  or  from  constipa- 
tion, and  must,  therefore,  be  considered  together  with 
the  disorders  that  accompany  them. 

Open  ulcers  argue  against  the  acceptance  of  the  risk, 
as  they  may  be  caused  by  syphilis  or  a  general  deterior- 
ation of  the  constitution.  If  the  cause,  however,  can  be 
proved  to  be  of  harmless  character,  the  foregoing  opinion 
may  be  much  modified. 

All  skin  diseases  arising  from  constitutional  taint 
permanently  disqualify. 

The  habits  of  the  applicant  with  reference  to  the  use 
of  malt  or  spirituous  liquors  cannot  be  too  carefully 
investigated  by  the  examiner.  The  line  at  which  tem- 
perance ends  and  intemperance  begins  is  so  vaguely 
drawn  in  the  minds  of  the  larger  class,  that  it  is  not  safe 
to  trust  the  statement  of  every  man  who  tells  you  that 
he  is  "  temperate  "  in  the  use  of  liquors  or  "  only  drinks 
occasionally."  The  kind  of  liquor  used,  the  frequency 
of  its  use,  and  the  duration  of  the  habit  must  be  ascer- 
tained, and  from  these  data  the  examiner  must  form  his 


THE   IMPERFECT   MAN.  169 

own  estimate.  Temperance  at  the  time  of  the  examina- 
tion is  no  proof  that  serious  damage  has  not  been  done 
iii  the  previous  life.  The  reformed  drunkard  is  one  of 
the  poorest  of  risks. 

A  pulse  rate  of  more  than  eighty-five  beats  per 
minute  is  objectionable.  Where  all  other  points  are 
favorable  this  limit  may,  in  rare  instances,  be  slightly 
exceeded.  '  Nothing  over  eighty,  however,  should  pass 
unchallenged.  Again,  a  pulse  of  less  than  sixty  beats 
per  minute  (unless  traceable  as  a  family  characteristic) 
might  indicate  some  serious  lesion  of  the  heart  or 
nervous  system.  An  irregular  or  intermittent  pulse 
may  be  the  result  of  severe  nervous  strain  or  excess  in 
the  use  of  tobacco.  It  is  usually,  however,  regarded  as 
a  more  serious  symptom,  and  indicative  of  cardiac  lesion 
or  marked  constitutional  impairment.  Such  a  pulse 
calls  for  re-examination,  if  not  for  immediate  rejection. 

Disorders  and  diseases  of  the  heart  have  already  been 
considered  in  detail.  All  organic  heart  lesions  reject. 
Functional  derangements  demand  re-examination.  In 
the  examination  of  the  heart,  not  only  the  physical 
signs,  but  also  all  constitutional  symptoms,  family 
history,  and  past  personal  history,  should  be  carefully 
reviewed  before  the  examiner  asserts  that  the  organ  is 
sound. 

The  same  remarks  hold  good  in  the  examination  of 
the  lungs.  Any  clue  pointing  to  possible  lung  affection 
should  be  followed  to  its  end.  All  points  that  can  bear 
upon  the  question,  whether  directly  or  indirectly,  should 
be  given  due  consideration.  If  the  examiner  regards 
every  applicant  as  possessed  of  lung  trouble  until  the 
12 


170  TKEATISE  ON   MEDICAL   EXAMINATION. 

converse  is  proved,  the  percentage  of  mortality  from 
this  source  will  be  greatly  decreased. 

Occasional  indigestion,  following  the  use  of  unsuit- 
able food,  does  not  interfere  with  the  acceptance  of  the 
risk.  If,  however,  the  dyspepsia  is  of  severe  form,  par- 
ticularly if  it  is  caused  by  the  abuse  of  alcohol,  rejection 
should  be  the  rule.  All  gastric  disorders  dependent 
upon  organic  disease  of  the  stomach  or  other  organs 
forbid  insurance. 

Disorder  of  the  liver  due  to  mere  portal  congestion 
does  not  disqualify.  Residence  in  a  malarial  district, 
the  use  of  alcoholic  liquors,  or  existing  disease  of  kid- 
neys or  spleen  demand  that  the  examination  of  the 
liver  be  thoroughly  made.  A  history  of  gall  stone 
should  make  the  examiner  cautious  in  forming  his 
decision. 

As  before  stated,  a  careful  examination  of  the  urine 
is  important  in  every  case.  The  rules  for  the  estima- 
tion of  genito-urinary  affections  have  been  given  so 
fully  in  the  section  devoted  to  these  organs,  that  they 
need  not  be  here  repeated. 

Evidence  of  disease  of  the  nervous  system,  unless  such 
disease  is  of  trifling  character  and  localized,  renders  any 
risk  extremely  hazardous.  Such  disease  is  apt  to  prove 
most  violent  and  dangerous  in  advanced  years,  owing 
to  the  progressive  degeneration,  the  gradual  decay,  that 
time  produces  in  the  organs  and  blood  vessels  of  the 
human  frame. 

In  thus  summing  up,  the  attempt  has  not  been  made 
to  review  in  detail  all  that  has  gone  before,  but  merely 
to  place  before  the  examiner  a  few  of  the  more  general 


THE   IMPOKTANCE   OF   ESTIMATING   A   EISK.       171 

principles,  which  he  may  analyze  and  apply  to  the  needs 
of  each  individual  case. 


THE  IMPOETANCE  OF  ESTIMATING  A  RISK. 

In  the  same  manner  that  a  thorough  acquaintance 
with  every  branch  of  medical  and  surgical  science  is 
requisite  for  the  successful  exhibition  of  efficient  reme- 
dies in  disease  or  for  the  assurance  that  should  attend 
the  surgical  operation,  so,  also,  does  that  special  branch 
connected  with  life  insurance  demand  the  study  and 
attention  of  the  Medical  Examiner,  in  order  that  he 
may  the  more  certainly  detect  the  presence  of  dele- 
terious factors  in  the  human  system,  estimate  their 
influence  on  the  duration  of  life,  and  render  a  decision 
that  shall  be  just  and  fair,  both  to  the  applicant  and  to 
the  insurance  company  whose  interest  he  represents. 

It  is  from  the  external  man,  from  the  circulatory,  the 
respiratory,  digestive,  secretory,  urinary,  and  nervous 
systems,  from  the  presence  of  hereditary  taints,  and  from 
any  other  attendant  condition  that  antagonizes  human 
life,  that  the  examiner  is  obliged  to  obtain  the  precise 
information  on  which  this  intelligent  judgment  and  fair 
and  equitable  decision  shall  be  based.  The  author,  there- 
fore, has  taken  special  pains  to  map  out  and  simplify 
the  various  diseases,  lesions,  hereditary  taints,  or  attend- 
ing conditions  which  may  exist  and  impair  the  health 
and  normal  expectancy  of  life  in  the  person  of  the 
applicant.  At  the  same  time  he  has  not  lost  sight  of 
the  fact  that,  whilst,  on  the  one  hand,  there  may  be  a 
number  of  circumstances  which  militate  against  the 
admissibility  of  a  risk,  there  may  be,  on  the  other  hand, 


172  TREATISE  ON   MEDICAL   EXAMINATION. 

such  opposite  conditions  as  not  only  to  overbalance  the 
objectionable  features,  but  to  decide  the  case  as  being 
safely  insurable.  Again,  the  case  may  seem,  at  first 
sight,  most  favorable  for  insurance,  and  yet,  further 
investigation  may  develop  such  unfavorable  conditions 
as  will  make  it  imperative  for  the  examiner  to  reject 
the  risk  without  hesitation. 

All  possibilities  of  the  kind,  bearing  on  the  affirm- 
ative or  the  negative  decision  of  a  case,  are,  of  course, 
confided  exclusively  to  the  examiner's  intelligent  dis- 
cretion, and  on  him  rests  the  serious  responsibility, 
that  no  worthy  applicant,  on  the  one  hand,  shall  be 
debarred  from  his  rightful  privilege,  and  no  insurance 
company,  on  the  other,  be  defrauded  of  its  resources  by 
the  recommendation  of  poor  risks.  These  consider- 
ations affect  alike  the  standing  and  integrity  of  the 
medical  examiner  and  the  pecuniary  interest  of  the 
insurance  company. 


APPENDIX, 


APPENDIX. 


Estimation  of  Specific  Gravity  when  the  Quan- 
tity of  Urine  is  Small. — When  the  quantity  of  urine 
furnished  is  not  sufficient  to  properly  float  the  urino- 
meter,  an  approximate  result  may  be  obtained  by  dilu- 
tion and  calculation.  For  instance,  suppose  that  only 
one-third  of  the  proper  quantity  can  be  obtained.  Add 
to  this  twice  the  volume  of  distilled  water,  agitate,  and 
take  the  specific  gravity  of  the  mixture.  If  the 
specific  gravity  of  this  mixture,  of  which  one-third  is 
urine,  is  1006,  then  the  specific  gravity  of  the  urine 
will  be  1000  +(6x3)  ==  1018.  A  finely  graduated 
urinometer  must  be  used,  for  it  will  readily  be  seen 
that  any  error  in  the  reading  will  be  exaggerated  three- 
fold in  the  result. 

Shipping  of  Urine. — It  may  sometimes  be  neces- 
sary to  send  urine  to  a  distance  for  examination.  In 
this  event,  the  urine  should  be  recently  passed.  Not 
less  than  three  ounces  should  be  taken.  The  bottle 
should  be  thoroughly  cleansed  and  filled  with  the  urine 
to  the  very  cork,  so  that  all  air  is  excluded.  A  pinch 
of  salicylic  acid  added  will  prevent  decomposition,  and 
in  no  way  interfere  with  the  tests. 


175 


176 


APPENDIX. 


MALE  LIFE  PISEASES  AND  NUMBER  OP  DEATHS  BY  STATES 
AND  TERRITORIES,  ETC.,  IN  TWENTY-SEVEN  LIFE  INSUR- 
ANCE COMPANIES,  DURING  A  PERIOD  OF  THIRTY  YEARS.* 


Typhoid  and  Typhus. 

N 

(ri 

Consumption. 

•a 
| 

h 

3 

Apoplexy. 

Other  Nervous 

a 

i 

R 

1 

£ 

Other  Respiratory. 

S 
£ 

i 

5 

Kidney  Diseases. 

Injuries  and  Accidents. 

1 

All  Other  Diseases. 

1 

3 

Alabama  

10 

38 
1 
179 

4 
7 
1 
8 
1 

50 
21 
78 
1 
165 
11 
23 
10 
45 

26 
6 
121 
3 
314 
10 
50 
10 
20 

7 
3 
38 
1 
96 
4 
7 

*6 

10 
2 
47 
2 
67 
3 
9 

12 

23 
8 
84 
1 
148 
3 
21 
4 
20 
1 

12 

4 
67 
1 
131 

2 
9 
6 

7 

20 
11 
63 
2 
108 
7 
19 
3 
16 

22 
1 
38 
2 
71 
2 
13 
3 
14 

40 
10 
65 
2 
122 
11 
17 
2 
25 

5 
20 
42 
"i 

2 

26 
11 
92 
6 
103 
3 
8 
7 
14 
4. 

3 

24 
1 
19 

"4 

i 

6 
5 
30 
1 
83 

i-2 

2 

7 

206 
82 
805 
24 
1648 
60 
203 
48 
197 
6 
2338 
996 
578 
141 
557 
398 
816 
979 
4108 
945 
356 
220 
1302 

108 
600 
1029 
6 
7443 
181 
2186 
36 
2949 
377 
101 
441 
225 
9 
281 
205 
6 
84 
1362 
45 
439 
264 

California   

District  of  Columbia. 
Florida  

Idaho  

Illinois  .    

151 
63 
33 
11 
19 
9 
74 
54 
297 
69 
43 
7 
75 

9 
58 
54 

270 
135 
65 
21 
73 
112 
114 
104 
392 
105 
20 
54 
277 

13 

60 
97 

398 
181 
97 
19 
93 
54 
158 
176 
857 
162 
70 
26 
178 

11 

110 

249 

106 
37 
28 
7 
24 
12 
47 
57 
229 
41 
9 
9 
49 

P 

22 
44 

92 
24 
19 
1 
33 
•18 
18 
59 
182 
40 
21 
13 
66 

2 
33 
49 
1 

233 
92 
73 
14 
49 
44 
79 
113 
379 
77 
29 
14 
122 

14 

65 
97 

105 
38 
36 
3 
26 
13 
34 
66 
244 
51 
20 
9 
49 

2 
23 
74 
3 

235 
126 
46 
13 
53 
15 
48 
82 
245 
91 
30 
20 
101 

10 
40 
73 

143 

68 
38 
5 
33 
14 
50 
57 
207 
55 
25 
10 
71 

6 
40 
46 
1 
473 
11 
160 
3 
157 
11 
7 
16 
13 
1 
15 
9 

261 
98 
62 
13 
49 
50 
64 
91 
275 
95 
30 
24 
120 

14 

56 
95 

661 
29 
233 
3 
325 
35 
17 
46 
34 
2 
29 
17 

46 
11 
11 
4 
8 
10 
12 
22 
136 
13 
9 
2 
16 

1 
13 
32 

290 
3 
38 

85 
10 
3 
4 
1 

"i 

3 

206 
83 
39 
22 
57 
31 
73 
49 
359 
88 
40 
19 
99 

16 
41 
52 

422 
9 
185 
5 
174 
16 
2 
27 
21 
1 
21 
20 

25 
12 
9 
4 
19 
2 
12 
6 
51 
21 
2 
1 
17 

1 
5 
11 

95 

33 
1 

35 
3 

"e 

5 

"2 
1 

76 
28 
22 
4 
21 
14 
33 
43 
225 
37 
8 
12 
62 

4 
34 
56 
1 
346 
6 
35 

170 
18 
3 
14 
10 

12 

7 

Maine        .  .. 

Maryland  

Massachusetts  
Michigan 

Minnesota  

Mississippi     .  .. 

Missouri  

Montana,  Nebraska 
and  Nevada  
New  Hampshire  
New  Jersey  

New  York 

449 
7 
140 
2 
199 
15 
3 
8 
7 

643 
39 
232 
3 
264 
38 
13 
160 
51 

1431 
25 
408 
8 
575 
80 
14 
63 
20 

395 
7 
91 
3 
167 
24 
6 
8 
10 

424 
6 
111 
3 
135 
26 
10 
24 
9 
1 
13 
13 
1 
10 
46 

23 
25 

1703 

768 
14 
203 
1 
291 
42 
10 
22 
18 
3 
24 
17 
1 
10 
106 

45 
21 

3403 

474 
8 
91 
1 
195 
29 
4 
16 
6 

17 
17 

572 
17 
166 
3 
174 
30 
9 
27 
20 
1 
23 
14 
2 

North  Carolina  

Ohio       

Pennsylvania  

Rhode  Island  
South  Carolina  

Texas 

Utah 

Vermont  
Virginia  
Washington  

25 
15 

33 
33 
1 
6 
142 
5 
37 
33 

4049 

58 
34 
1 
13 
227 
2 
73 
41 

8 
5 

"i 

71 

1 
9 
11 

West  Virginia.  
Wisconsin 

5 
121 
1 
29 
6 

2 
51 

24 
17 

1987 

7 
114 
4 
36 
16 

5 
86 
1 
45 
17 

15 

145 
1 
39 
22 

17 

1 
10 
2 

5 

139 
4 
46 
33 

1 
33 
1 
5 
3 

4 
64 
24 
19 
17 

Unknown  

British  America  
Other  Foreign  

Total 

2307 

6472 

1705 

2711 

2056 

3345 

887 

2678 

474 

1665 

35442 

*  A  Treatise  on  the  Records  of  Thirty  American  Life  Offices.     By  Levi  W.  Meech,  in  charge  of 
a  committee  of  actuaries. 


APPENDIX. 


177 


PROPORTIONAL  DEATHS  AND  DISEASES  TO  10,000  MALES 
LIVING  IN  EACH  GROUP  OF  STATES. 


I. 

II. 

III. 

IV. 

V. 

130.5 

VI. 

VII. 

MEAN  GROUP. 

GROUPS. 

All  Causes           . 

105.3 

97.7 

107.1 

104.5 

170.5 

112.2 

SUMMARY: 

17.6 
26.4 
15.4 
6.6 
13.3 
8.6 
17.4 

18.5 
21.4 
11.5 
4.4 
14.6 
10.0 
17.3 

16.6 

27.9 
15.4 
7.3 
12.1 
11.2 
16.6 

18.7 
23.0 
14.4 
4.6 
16.6 
11.2 
16.0 

27.5 
27.3 
20.1 
6.7 
18.1 
11.9 
18.9 

48.4 
26.3 
22.3 
6.8 
21.5 
22.0 
23.2 

15.9 
22.1 
18.4 
9.2 
146 
9.1 
22.9 

23.3 
24.9 
16.8 
6.5 
15.8 
12.0 
18.9 

I. 

New  England. 
New  York. 

II. 

Northwest. 
Michigan. 
Wisconsin. 
Minnesota. 
Nebraska. 

HI. 

New  Jersey. 
Pennsylvania. 

IV. 

Ohio. 
Indiana. 
Illinois, 
[owa. 
Kansas. 

V. 

Delaware. 
Maryland. 
Dist.  Columbia. 
Virginia. 
Kentucky. 
Missouri. 

VI. 

South  of  36°  30'. 
North  Carolina. 
South  Carolina. 
Tennessee. 
Georgia. 
Florida. 
Alabama. 
Mississippi. 
Arkansas. 
Louisiana. 
Texas. 

VII. 

Washington. 
Oregon. 
California. 
Utah. 
Dakota. 
New  Mexico. 

Constitutional 

Nervous  

Circulatory  
Respiratory  

Digestive   

Miscellaneous  

ZYMOTIC  : 
Typhoid,  Typhus  
Malarial  Fever  

7.6 
1.7 
1.0 
1.7 
.9 
.9 
.3 
3.6 

8.5 
2.3 
1.3 
1.4 
.7 
.8 
.3 
3.2 

6.8 
1.8 
1.0 
.9 
1.0 
1.1 
.3 
3.7 

6.7 
3.3 
1.3 
1.4 
1.8 
2.0 
.4 
2.8 

6.9 
3.8 
1.3 
3.6 
1.6 
3.5 
.5 
6.3 

4.8 
11.8 
1.5 
5.8 
3.6 
2.4 
.3 
18.2 

5.2 
1.9 
2.2 
1.5 
.2 
.9 
.6 
3.4 

6.6 
3.8 
1.4 
2.3 
1.3 
1.7 
.4 
5.9 

Diarrhoea           .. 

Cholera  

Other  Zymotic  

CONSTITUTIONAL  : 
Dropsy 

1.8 
2.1 
20.8 
1.7 

1.6 
1.5 
16.9 
1.4 

2.6 
2.1 
22.2 
1.0 

1.9 
1.6 
18.5 
1.0 

2.2 
2.2 
21.5 
1.4 

2.2 
1.1 
21.0 
2.0 

1.9 
1.9 
16.9 
1.4 

2.0 
1.8 
19.7 
1.4 

Consumption    

Other  Constitutional. 

NERVOUS  : 

5.2 
1.5 

7.2 
.3 
1.2 

3.8 
1.5 

5.2 
.3 
.7 

5.0 
2.1 

6.5 
.6 
1J 

4.2 
2.5 

6.2 
.4 
1.1 

72 
2.9 

7.8 
.5 
1.7 

8.2 
4.9 

7.5 
.7 
1.0 

6.8 
1.7 

7.3 
1.5 
1.1 

5.8 
2.4 

6.8 
.6 
1.1 

Congestion  Brain  
Paralysis,    Softening 
Brain  

Epilepsy,Convulsions 
Other  Nervous  

CIRCULATORY  : 
Diseases  of  Heart  
Other  Circulatory  

6.1 
.5 

4.1 
.3 

7.1 
.2 

4.4 
.2 

6.3 
.4 

6.6 

.2 

7.4 
1.8 

6.0 
.5 

RESPIRATORY  : 
Pneumonia  

7.3 
1.8 
1.8 

1.9 
.4 

8.5 
1.7 
2.0 

2.0 
.4 

6.6 
1.2 
1.5 

2.0 
.8 

9.8 
1.7 
2.0 

2.4 

.7 

10.8 
22.2 
1.8 

2.4" 
.9 

12.6 
22.2 
3.4 

1.9 
1.4 

9.0 
.9 
2.2 

1.8 
.7 

9.2 
1.7 
21 

2.1 
.8 

Congestion  Lungs  
Bronchitis,  Pleurisy- 
Abscess  Hemorrhage 

Other  Respiratory  

DIGESTIVE  : 
Diseases  of  Stomach- 
Diseases  of  Bowels  ... 
Peritonitis 

1.6 
1.9 
.7 
2.7 
1.7 

2.2 
2.2 
.8 
24 
2.3 

2.0 
2.5 
1.0 
3.7 
2.0 

1.9 
2.5 
.8 
3.7 
2.3 

2.1 
2.5 

.7 
3.9 
2.7 

5.1 

6.8 
.5 
4.8 
5.8 

1.3 
1.6 
.3 
4.2 
1.7 

2.3 
2.7 
.7 
3.6 
2.6 

Diseases  of  Liver  
Other  Digestive  

MISCELLANEOUS: 
Diabetes  

.5 
3.5 
.9 

.5 
1.4 
.8 

.5 
3.1 
1.1 

.4 
1.9 

.5 

.8 
2.1 
.9 

.3 
2.4 
1.2 

.6 
2.6 

.7 

.5 
2.4 
.9 

Diseases  of  Kidney... 
Other  Urinary  
Childbirth,  Puerperal 

Diseases  Breast  and 
Uterus  

Abscesses,    H  e  m  o  r- 
rhage  and  Old  Age- 
Debility,  Exhaustion, 
etc 

1.2 

1.0 
7.2 
1.3 
1.8 

.8 

1.0 
9.7 
2.1 
1.0 

1.1 

2.4 
6.0 
1.3 
1.1 

1.1 

.7 
9.0 
1.3 
1.1 

1.3 

1.3 
9.3 
1.8 
1.4 

1.0 

1.1 
13.3 
1.4 
2.5 

.3 

1.2 
12.8 
3.3 
1.3 

1.0 

1.2 
9.6 
1.8 
1.5 

Accidents,  Injuries... 
Suicides  .. 

Unknown  Causes  

115,273    2,716  1  3,976    6,239  1  3,306    2,153  |     863  || 

178 


APPENDIX. 


A  SANITARY  SURVEY  OF  THE  UNITED  STATES. 

The  respective  annexed  figures  are  arranged  in  ascending  order,  to  show  the  proportional 
deaths  by  each  disease  among  10,000  insured  males  living  in  each  group  of  States. 

The  columns  with  single  figures  refer  to  the  seven  groups  of  States  in  the  margin. 


DISEASES. 

LEAST  MORTALITY.                igSSS. 

\ 

GROUP. 

All  Causes  

2   97.7 

4104.5 

1  105.3J 

3  107.1 

7  112.2 

5  130.5 

6  170.5 

118.3 

SUMMARY  : 
Zymotic      . 

15.9 
21.4 
11.5 
4.4 
12.1 
8.6 
16.0 

3    16.6 
7    22.1 
i    14.4 
4     4.6 
1    13.3 
7      9.1 
3    16.6 

1    17  6 

I    185 

1    187 

5    27.5 
5    27.3 
5    20.1 
3      7.3 
5    18.1 
5    11.9 
7    22.9 

6    48.4 
3    27.9 
6    22.3 
7      9.2 
6    21.5 
6    22.0 
6    23.2 

23.3 
24.9 
16.8 
6.5 
15.8 
12.0 
18.9 

1. 

New  England. 
New  York. 

2. 

Northwest. 
Michigan. 
Wisconsin. 
[Minnesota. 
Nebraska. 

3. 

New  Jersey. 
Pennsylvania. 

4. 

Ohio. 
Indiana. 
Illinois. 
Iowa. 
Kansas. 

5. 

Delaware. 
Maryland. 
Dist.  Columbia. 
Virginia. 
Kentucky. 
Missouri. 

6. 

South  of  36°  30'. 
North  Carolina. 
South  Carolina. 
Tennessee. 
Georgia. 
Florida. 
Alabama. 
Arkansas. 
Louisiana. 
Texas. 

7. 

Pacific,  etc. 
Washington. 
Oregon. 
California. 
Dakota. 
Utah. 

Constitutional  

4   23.0 
1    15.4 
I      6.6 
2    14.6 
2    10.0 
2    17.3 

3    26.3 
J    15.4 
j      6.7 
I    14.6 
i    11.2 
L    17.4 

I    26.4 
7    18.4 
6      6.8 
4    16.6 
4    11.2 
5    18.9 

Circulatory  
Nervous  , 

Respiratory  , 

Digestive..  ..«.•«••••.«...*•• 
Miscellaneous  

ZYMOTIC: 
Typhoid  and  Typhus. 
Malarial  Fever  
Erysipelas 

4.8 
1.7 
10 

r    5.2 

J      1.8 
i      10 

I      6.7 
f      1.9 
I      i  3 

5      6.8 
I     2.3 
[      1  3 

j      6.9 
1     3.3 
j      13 

I      7.6 
5      3.8 
3      1.5 
3      3.6 
5      1.6 
3      2.4 
5        .5 
5      6.3 

,  J 

!  "1 

5      5.81 
5      3.6J 
3      3.51 

r     .63 

3    18.2^ 

6.6 
3.8 

1.4| 

1 

5.9 

.9 
.2 
.8 

I     1.4 

j.      1.4 

1.5 

I      1.7 
3      10 

9 

t       .i 

Cholera  

*      1.1 
5        .3 
L      3.6 

[     2.0 
t       .'. 
3     3.7 

.3 

2.8 

I       .3 

2      3.2 

'     s!< 

Other  Zymotic  

CONSTITUTIONAL  : 

1.6 
1.1 
16.9 
1.0 

L      1.8 
2      1.5 
I    16.9 
5      1.0 

t      1.9 
t     1.6 
t    18.5 
2      1.4 

1.9 
1.9 
20.8 
1.4 

5      2.2 
L      2.1 
5    21.0 

r    1.4 

5      2.2 
J      2.1 
>    21.5 
L      1.7 

*      2.6l 
j      2.21 
J    22.21 
3      2.0J 

2.0 

$ 

1.4 

Other  Constitutional. 

NERVOUS  : 

3.8 
1.5 
5.2 

1 

t     4.2 
2      1.5 
t     6.2 

I       .3 
>     1.0 

5     5.0 

r    1.7 

I      6.5 
L       .4 

r    1.1 

5.2 
2.1 

7.2 

.5 
1.1 

r    e.s 

I      2.5 
f      7.3 

$        .6 
J     1.2 

)      7.2 
>      2.9 
5      7.5 

L      1.2 

5      8.21 
3      4.91 
>     7.8l 

)     1.7! 

5.8 
2.4 
6.8 

,: 

Congestion  Brain  
Paralysis,    Softening 

Epilepsy  and  Convul- 

Other  Nervous  

CIRCULATORY:               i 
Diseases  of  Heart  K 
Other  Circulatory  r6 

4.1 
.2 

L      4.4 
I       .2 

6J 

6.J 

3      6.6 
.4 

J     7.1 
L        .5 

i  4 

3 

RESPIRATORY: 
Pneumonia.  , 

6.6 
.9 
1.5 

1.8 
.4 

7.3 
1.2 
1.8 

1.9 
.4 

8.5 
1.7 
1.8 

1.9 

.7 

2.0 
1.7 
2.0 

2.0 

t     9.8 
1.8 
t      2.0 

!      2.0 
t        .8 

>    10.8 
»      2.2 

'      2.2 

)      2.4 
»        .9 

;'d 

>      3.4J 

i  d 

9.2 
1.7 
2.1 

5 

Congestion  of  Lungs. 
Bronchitis,  Pleurisy- 
Abscess  Hemorrhage 
of  Lungs  
Other  Respiratory  

DIGESTIVE  : 
Diseases  of  Stomach.. 
Diseases  of  Bowels... 
Peritonitis 

1.3 
.9 
1.5 

1.8 
.4 

1.6 
1.2 
1.8 
1.9 
.4 

1.9 
1.7 
1.8 
1.9 

.7 

2.0 
1.7 

2.0 
2.0 

.7 

2.1 

1.8 
2.0 
2.0 
.8 

2.3 
2.2 
2.2 
2.4 
.9 

MJ 

a 

2.41 
1.4| 

2.3 
1.7 
2.1 

2.1 
.8 

Diseases  of  Liver  
Other  Digestive  

MISCELLANEOUS: 
Diabetes          

.3 
1.4 
.5 

.3 

.7 
.6 
1.3 
1.0 

.4 
1.9 

Y 

.8 

1.0 
7.2 
1.3 
1.1 

.5 
2.1 

.8 

1.0 

1.0 
9.0 
1.3 
1.1 

.5 
2.4 
.9 

1.1 

1.1 

9.3 
1.4 
1.3 

.5 
2.6 
.9 

1.1 

1.2 
9.7 
1.8 
1.4 

.6 
3.1 
1.1 

1.2 

1.3 

12.8 
2.1 
1.8 

2.4] 
13.31 
3.31 
2.5] 

.5 
2.4 
.9 

1.0 

1.2 

9.6 
1.8 
1.51 

Diseases  of  Kidney... 
Other  Urinary  
Abscess  Hemorrhage, 
Old  Age  
Debility,  Exhaustion 
and  Prostration  
Accidents  

Suicides  

Unknown  Causes  

APPENDIX. 


179 


A  GENERAL  TABLE  OF  DISEASES  AND  DEATHS  IN  TWENTY- 
SEVEN  LIFE  INSURANCE  COMPANIES  DURING  A  PERIOD 
OF  THIRTY  YEARS.  • 


DISEASES. 

NUMBER  OF  DEATHS. 

PER  CENT. 
or  TOTAL. 

Males. 

Females. 

Total. 

All  Causes  

35,442 

2,182 

37,624 

100.00 

SUMMARY  : 

6,356 
8,175 
5,106 
1,986 
4,771 
3,344 
5,704 

303 

548 
193 
106 
291 
273 
468 

6,659 
8,723 
5,299 
2.092 
5,062 
3,617 
6,172 

17.70 
23.19 
14.08 
5.56 
13.45 
9.61 
16.42 

Constitutional  Diseases                 .               

Digestive  Diseases        

ZYMOTIC  DISEASES: 

2,147 
159 
23 
252 
412 
159 
213 
46 
255 
298 
13 
38 
127 
374 
70 
62 
12 
587 
328 
431 
195 
4 
11 
1 
21 
117 
1 

107 
11 
1 
6 
25 
7 
13 
4 
12 
7 
2 
2 
6 
10 
4 
1 
2 
35 
22 
15 
8 
0 
0 
0 
0 
1 
2 

2,254 
170 
24 
258 
437 
166 
226 
50 
267 
305 
15 
40 
133 
384 
74 
63 
14 
622 
350 
446 
203 
4 
11 
1 
21 
118 
3 

5.99 
.45 
.06 
.69 
1.16 
.44 
.60 
.13 
.71 
.81 
.04 
.11 
.35 
1.02 
.20 
.17 
.04 
1.65 
.93 
1.19 
.54 
.01 
.03 
.00 
.06 
.31 
.00 

Yellow  Fever  

Remittent  Fever 

Measles  

Scarlet  Fever 

Diphtheria  and  Malignant  Sore  Throat.  

Pysemia  

Diarrhoea                                                ....         .  . 

Cholera  

Cholera  Morbus      .  .         

Goitre 

Malignant  Pustule    

Glanders                    .... 

Purpura  Hemorrhagica   

Alcoholism                       .       .        .              

CONSTITUTIONAL  DISEASES: 

59 
621 
622 
63 
169 
61 
10 
11 
25 
88 
12 
6,474 
10 

12 
44 
56 
0 
11 
0 
1 
0 
6 
5 
0 
412 
1 

71 
665 
678 
23 
180 
51 
11 
11 
31 
93 
12 
6,886 

.19 
1.77 
1.80 
.06 
.48 
.14 
.03 
.03 
.08 
.25 
.03 
18.31 
.03 

Gout  

Tabes  Mesenterica       

Consumption        

Other  Constitutional  Diseases    .  .        

180  APPENDIX. 

GENERAL  TABLE  OF  DISEASES  AND  DEATHS  (CONTINUED). 


* 
DISEASES. 

NUMBER  OF  DEATHS. 

PER  CENT. 
OF  TOTAL. 

Males. 

Females. 

Total. 

All  Causes  

35,442 

2,182 

37,621 

100.00 

NERVOUS  DISEASES: 

1,705 
855 
399 
841 
721 
130 
140 
2 
1 
277 
1 
1 
8 
48 
17 
3 
47 
18 
41 
3 
48 

61 
14 
9- 
32 
37 
8 
6 
0 
0 
10 
0 
0 
0 
3 
1 
0 
4 
0 
2 
0 
6 

1,766 
669 
408 
873 
758 
138 
146 
2 
1 
287 
1 
1 
8 
51 
18 
3 
51 
18 
43 
3 
54 

4.70 

1.78 
1.09 
2.32 
2.02 
.37 
.39 
.01 
.00 
.76 
.00 
.00 
.02 
.14 
.05 
.01 
.14 
.05 
.11 
.01 
.14 

Paralysis                        .  .  . 

Disease  of  the  Brain  

Anxiety  

Fright                                    . 

Cerebral  Embolism             . 

Anaemia  of  the  Brain  

Progressive  Muscular  Atrophy  

Tetanus 

Inflammation  of  Spinal  Cord  

Disease  of  the  Spinal  Cord 

Congestion  of  the  Spinal  Cord  

Other  Nervous  Diseases  

CIRCULATORY  DISEASES: 
Disease  of  the  Heart 

1,297 
104 
100 
98 
42 
56 
4 
27 
5 
79 
51 
16 
5 
18 
18 
8 
112 
437 
172 
568 
2,713 
78 
283 
264 
63 
34 
13 
16 
10 
66 

62 
9 
4 
6 
3 
6 
0 
1 
0 
4 
1 
1 
1 
0 
2 
0 
3 
21 
7 
20 
176 
6 
7 
31 
8 
1 
0 
0 
2 
6 

1.359 
113 
104 
104 
45 
62 
4 
28 
5 
83 
52 
17 
6 
18 
20 
8 
115 
458 
179 
597 
2,889 
84 
290 
295 
71 
35 
13 
16 
12 
72 

3.61 

.30 
.28 
.28 
.12 
.16 
.01 
.07 
.01 
.22 
.14 
.05 
.02 
.05 
.05 
.02 
.31 
1.21 
.48 
1.59 
7.68 
.22 
-.77 
.78 
.19 
.09 
.03 
.04 
.03 
.19 

Pericarditis  and  Endocarditis  

Valvular  Disease  of  the  Heart 

Fatty  Degeneration  of  the  Heart  

Atrophy  of  the  Heart  

Paralysis  of  the  Heart  

Angina  Pectoris  

Embolus  of  Pulmonary  Artery  

Phlebitis 

Other  Circulatory  Diseases 

Epistaxis  

Pleurisy   .  .. 

Disease  of  Lungs  .'.  

Gangrene  of  Lungs  

(Edema  of  Lungs    

APPENDIX.  181 

GENERAL  TABLE  OF  DISEASES  AND  DEATHS  (CONTINUED.) 


DISEASES. 

*       NUMBER  or  DEATHS. 

PER  CKNT. 
OF  TOTAL. 

Males. 

Females. 

Total. 

All  Causes 

35,442 

2,182 

37,624 

100.00 

DIGESTIVE  DISEASES: 
Inflammation  of  Stomach  

319 
75 
150 
57 
23 
4 
425 
67 
84 
22 
100 
36 
6 
246 
165 
127 
43 
69 
43 
3 
11 
12 
22 
7 
41 
35 
9 
75 
11 
268 
104 
79 
448 
63 
36 
9 
15 
15 
4 
2 
14 

39 
6 
5 
1 
2 
0 
45 
6 
2 
5 
10 
1 
1 
41 
17 
7 
12 
3 
3 
0 
0 
0 
0    , 
1 
8 
3 
0 
0 
2 
15 
4 
7 
19 
3 
2 
0 
1 
0 
0 
0 
2 

358 
81 
155 
58 
25 
4 
470 
73 
86 
27 
110 
37 
7 
287 
182 
134 
55 
72 
46 
3 
11 
12 
22 
8 
49 
38 
9 
11 
77 
283 
108 
86 
467 
66 
38 
9 
16 
15 
4 
2 
16 

.95 
.22 
.41 
.15 
.07 
.01 
1.25 
.19 
.23 
.07 
.29 
.10 
.02 
.76 
.48 
.36 
.15 
.19 
.12 
.01 
.03 
.03 
.06 
.02 
.13 
.10 
.02 
.03 
.20 
.75 
.29 
.23 
1.24 
.18 
.10 
.02 
.04 
.04 
.01 
.01 
.04 

Disease  of  Stomach  

Ulceration  of  Bowels    

Congestion  of  Bowels  

Disease  of  Bowels    

Obstruction  of  Bowels 

Perforation  of  Bowels  

Peritonitis 

Gastro-enteritis  

Disease  of  Stomach  and  Bowels 

Strangulated  Hernia  

Gangrene  of  Tongue  

Fistula  in  Ano  

Disease  of  Spleen      

Leucocythaemia  

Hemorrhage  

Undefined  Diseases  of  Abdominal  Organs  
Jaundice  

Cirrhosis  of  Liver 

Abscess  of  Liver  

Congestion  of  Liver  

Fatty  Degeneration  of  Liver       

Biliary  Calculus                                                 .   . 

Obstruction  of  Hepatic  Duct  

Rupture  of  Gall  Bladder    .                      

Other  Digestive  Diseases  

MISCELLANEOUS  DISEASES: 

650 
60 
12 
1 
255 
158 
12 
74 
64 
5 
1 

17 
1 
0 
0 
9 
3 
0 
2 
1 
0 
0 

667 
61 
12 
1 
264 
161 
12 
76 
55 
5 
1 

1.51 
.16 
.03 

.70 
.43 
.04 
.20 
.15 
.01 

Diabetes  

Disease  of  Bladder    

Rupture  of  Bladder 

182  APPENDIX. 

GENERAL  TABLE  OF  DISEASES  AND  DEATHS  (CONTINUED.) 


DISEASES. 

NUMBER  OF  DEATHS. 

PER  CENT. 
OF  TOTAL. 

Males. 

Females. 

Total. 

\11  Causes  

35,442 

2,182 

37.624 

100.00 

MISCELLANEOUS  DISEASES  (Continued): 
Urinary  Calculi  

20 
33 
39 
5 
1 
66 

1 

0 
0 

? 

5 
197 
110 

28 
5 
9 
3 
0 
12 
34 
7 
24 

21 
13 

39 
5 
1 
71 

197 
110 
405 
122 
75 
58 
15 
99 
2,712 
482 
632 

.06 
.03 
.10 
.01 

.19 
.52 
.29 
1.08 
.32 
.20 
.15 
.04 
.26 
7.21 
1.28 
1.42 

Gravel         ....          .                    

Disease  of  Prostate  Gland  

Stricture  of  Urethra  

Other  Urinary  Diseases  

Childbirth  and  Puerperal  Diseases 

Debility,  Exhaustion  and  Prostration  

377 
117 

66 
55 
15 

87 
2,678 
475 
508 

Abscess 

Old  Age  

Suicides  

Unknown  Causas         .           ... 

IDSTDEX. 


ABDOMEN,  examination  of,  78. 

Addison's  disease,  138. 

Age,  influence  on  the  risk,  10,  162. 

Alcoholism,  25,  168 

Albumen,  tests  for,  103. 

Albuminuria,  118. 

Anaemia,  135. 

Aneurism,  46. 

Angina  pectoris,  44. 

Aphonia,  57. 

Apoplexy,  144. 

Appendix,  173. 

Applicant,  identity  of,  9. 

Arteries,  atheroma  of,  136,  145. 

Asthma,  63. 

BALDNESS,  11,  166. 

Bile  in  the  urine,  108. 

Blindness,  19,  167. 

Blood  diseases,  135. 

Blood  in  the  urine,  107. 

Brain  diseases,  hereditary  transmission 

of,  158. 
Brain,  softening  of,  146. 

tumors  of,  146. 
Bright's  disease,  1 19. 
Bronchitis,  62. 

CALCULI  in  the  kidney,  126. 
Cancer,  hereditary  transmission,  156. 
kidney,  126. 
liver,  89. 
lungs,  65. 
stomach,  83. 
Casts,  see  Tube-casts. 
Chest,  measurement  of,  54. 

tumors  of,  64. 
Circulatory  system,  31. 
Cirrhosis  of  liver,  90. 
Climacteric  period,  132. 
Climate,  23. 
Colic,  87. 

renal,  126. 
Complexion,  13. 
Constipation,  86. 
Consumption,  cough,  60. 

expression  of  countenance,  12. 
hereditary  transmission,  72. 
physical  signs,  72. 
symptoms,  70. 
Cough,  60. 
Countenance,  12. 

DEAFNESS,  19. 

Deformities,  21,  167. 
Development,  general  physical,  15, 163. 
Diabetes  insipidus,  117. 
mellitus,  129. 
Diarrhoea,  85. 
Digestive  system,  75. 
Dilatation  of  heart,  42. 
Diphtheria,  57. 


Dysentery,  chronic,  84. 

Dyspepsia,  80,  1 70. 

Dyspnoea,  54,  61. 

EMPHYSEMA,  62. 

Empyema,  67. 

Endocarditis,  39. 

Epilepsy,  148. 

Epithelial  cells  in  the  urine,  115. 

External  man,  the,  9. 

Eye,  ii. 

FAMILY  history,  162,  165. 

Fatty  degeneration  of  heart,  43. 

Fistula  in  ano,  21,  168. 

GALL  stones,  170. 

Gastritis,  chronic,  82. 

Gastrodynia,  79. 

Genito-urinary  organs,  116. 

Gout,  141. 

hereditary  transmission,  156. 
Gray  hair,  n. 

HAIR,  the,  II. 

Headache,  143. 

Heart  disease,  special  symptoms,  47. 

Heart,  functional  diseases,  44. 

location,  35. 

rhythm,  37. 

sounds,  37. 

valves,  36. 
Height,  1 6. 

Heller's  test  for  albumen,  103. 
Hemorrhage  from  lungs,  68. 
Hemorrhoids,  86,  168. 
Hereditary  transmission,  151. 
Hernia,  20,  167. 
Hodgkin's  disease,  138. 
Hydatid  tumors  of  liver,  90. 
Hydrothorax,  67. 
Hypertrophy  of  heart,  42,  47. 
Hysteria,  149. 

IDENTITY  of  the  applicant,  9. 
Imperfect  man,  165. 
Insanity,  149. 
Intemperance,  25,  1 68. 
JAUNDICE,  92. 
KIDNEY,  amyloid,  124. 

Bright's  disease,  119. 
cancer,  126. 
congestion,  119. 
diseases  of,  116. 
hemorrhage,  127. 
tuberculosis,  126. 
LARYNGITIS,  chronic,  56. 
Leucin,  112. 
Leucocythsemia,  137. 
Leucorrhoea,  133. 
Liver,  amyloid,  89. 

cancer,  89. 

cirrhosis,  90. 


183 


184 


INDEX. 


Liver,  diseases  of,  88,  170. 

fatty  degeneration,  88. 
hydatid  tumors,  90.- 
Locomotor  ataxia,  147. 
Loss  of  limb,  21. 
Lungs,  cancer,  65. 
collapse,  68. 
consumption,7o. 
diseases  of  59. 
hemorrhage,  68. 
syphilitic  affections,  65. 
MEASUREMENT  of  chest,  54. 
Metritis,  133. 

Microscopic  ex.  of  urine,  113. 
Miscarriage,  132. 
Mortality  tables,  176. 
Mucus  in  the  urine,  108. 
Murmurs,  analysis  of,  41. 
endocardial,  37. 
hsemic,  40,  48,  49. 
pericardial,  37. 
pseudo,  38. 

NEPHRITIS,  acute  tubal,  123. 

chronic  interstitial,  123. 

chronic  parenchymatous,  122 
Nervous  diseases,  143. 
OCCUPATION,  influence   on  risk, 

22,  165. 

(Esophagus,  strictures  of,  77. 
Oxalate  of  lime  in  the  urine,  III. 

PALPITATION,  45- 

Paralysis,  148. 

Pancreas,  diseases  of,  92. 

Perfect  man,  161. 

Pericarditis,  38. 

Peritonitis,  chronic,  85. 

Personal  history,  162,  166. 

Pharyngitis,  58. 

Phosphoric  acid  in  the  urine,  1 1 2. 

Piles,  86,  1 68. 

Plethora,  136.  ^ 

Pleurisy,  chronic,  66. 

Pleurodynia,  64. 

Pneumonia,  chronic,  66. 

Polyuria,  117. 

Pregnancy,  132. 

Premature  old  age,  II. 

Pulse,  character,  33,  34. 

frequency,  31,  163,  169. 

intermittent,  33. 

irregular,  33. 

volume,  33. 
Purpura,  138. 
Pus  in  the  urine,  109. 
QUINSY,  76. 

REFORMED  drunkards,  27. 
Respirations,  frequency  of,  53. 
Respiratory  organs,  acute  disease  of,  61. 
Respiratory  sounds,  60. 
Respiratory  system,  53. 
Responsibility  of  the  examiner,  171. 


Rheumatism,  139. 

hereditary  transmission,  157. 
SCROFULA,  15. 
Skin  diseases,  168. 
Smallpox,  20. 
Specific  gravity  small  amount  of  urine, 

!75- 

Spleen,  affections  of,  139. 
Stomach,  cancer,  83. 

dilatation,  83. 
diseases  of,  79. 
hemorrhage,  83. 
ulceration,  82. 
Sugar  in  the  urine,  105. 

tests  for,  1 06. 
Sunstroke,  150. 
Syphilis,  15,  57,  65,  159. 
TEMPERAMENT,  bilious,  15. 
nervous,  14. 
phlegmatic,  14. 
sanguine,  14. 
Throat,  catarrh  of,  57. 

ulcers,  58. 

Tobacco,  influence  on  heart,  45,  169. 
Tongue,  75. 
Tonsillitis,  76. 
Tremor,  148. 

Trommer's  test  for  sugar,  106. 
Tube-casts  in  the  urine,  113. 
blood,  144. 
epithelial,  114. 
fatty,  114. 
granular,  114. 
hyaline,  113. 
waxy,  113. 
Tyrosin,  112. 
ULCERS,  open,  168. 
of  stomach,  82. 
of  throat,  58. 
Urates,  in. 

Urea,  estimation  of,  109. 
Uric  acid,  no. 
Urine,  95. 

color,  97. 

microscopic  examination,  113. 
odor,  97. 
quantity,  99. 
reaction,  98. 
shipping,  175. 
specific  gravity,  100. 
taste,  98. 

Uterus,  diseases  of,  133. 
VACCINATION,  19. 
Valves  of  the  heart,  36. 
Valvular  heart  disease,  39. 
Vertigo,  144. 
Vital  capacity,  55,  63. 
WEIGHT,  deficient,  16,  167. 
excessive,  16,  167. 
normal,  17. 

proportioned  to  height,  17. 
Women,  insurance  of,  131. 


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